Pulp therapy for primary and young teeth

1. Pulp therapy in primary
and young Permanent
Teeth
Dr. Masar Mohammed

2. Pulp Therapy for Primary and
Young Permanent
Teeth
Introduction
Diagnostic
 Vital pulp therapy.
 - Pulp Capping
 a. Indirect pulp capping
 b. Direct pulp capping

3.  The primary objective of pulp therapy
is to maintain the integrity and health
of the teeth and their supporting
tissues.

4.  Pulp:
is defined as a special organ with a unique
environment of the unyielding dentin
surrounding a resistant, resilient soft tissue
of mesenchymal origin reinforced with a
ground substance. Morphology of pulp
basically deals with configuration or
structure of dental pulp.

5. Pulp cavity:
Deciduous:
o Dentin is thinner
o Enamel is thinner
o Pulp cavity is larger
o Pulp horns are high
in cusp region
Permanent:
o Dentin is thick
o Pulp cavity smaller
o Pulp horns  lower
in cusp region

6. Assessment (Cost-Benefit ratio)
Preoperative assessment is essential to
determine whether pulp therapy or extraction
is indicated.
We should consider the following:
1. Medical conditions.
2. Overall assessment of the mouth (space
management) and parental attitudes toward
dental health.
3. Assessment of the individual tooth.

7. 1- Medical conditions:
• Every effort should be made to conserve
teeth in hemophilia
• Children with systemic condition such as
congenital &acquired heart disease
• Trauma of operative dentistry results in
transient bacteraemia from the gingiva.
• Also nephritis, leukemia, solid tumors,
idiopathic and cyclic neutropenia

8. 2- Overall assessment of the mouth
(space management) and parental
attitudes toward dental health:
For example, the dentist may invest more time
and effort to save a pulplly involved 2nd 1ry molar
(E) in 4-year old child with unerupted 1st
permanent molars than to save a pulplly involved
1st 1ry molar (D) in 8-year.
Oral hygiene should be modified
Management of space loss
The dentist must evaluate parent attitude &
improve it by motivation & education

9. 3- Assessment of the individual tooth:
Three considerations must be kept in minds:
Can the tooth be restored if the pulp therapy
can be performed? -Nothing was gained, if
pulp therapy is successful, and the crown of
the involved tooth is non-restorable or the
periodontal structures are irreversibly
diseased. Stainless steel crown increase the
chance of crown restoration after pulp
therapy.

11.  Does the dental age of the child (warrant)
need retention of that particular tooth?-
Dental age judge by root development
( when roots of primary molars have been
more than half resorbed by the eruption of
succedaneous teeth, extraction should be
made.

12.  If the pulp status is amenable to pulp
therapy? - It will be answered in the
diagnostic aid in the selection of teeth for
vital pulp therapy.

13. Diagnostic
1. Physical condition of the patient
 Congenital cardiac disease
 Immunosuppressed patients
 Children with nephritis, leukemia,
tumors, cyclic neutropenia,
uncontrolled diabetes.

14. Diagnostic
2. History of pain
The history of either presence or absence of
pain is not reliable in the differential diagnosis
of the condition of the exposed primary pulp
as it is in permanent teeth.

15. Diagnostic
Provoked pain: is stimulated by heat, cold,
sweets, air and chewing When the
stimulus is removed the pain is reduced or
disappears.
These signs often indicate that the pulp is
vital

16.  Spontaneous pain
usually wakes a child at night and may not
relieve by analgesics. These signs usually
indicate advanced, irreversible pulp
damage

17. 3. Clinical Examination
 Abnormal tooth mobility
Tenderness to percussion
 Swelling
Size of exposure and amount of pulpal
bleeding
4. Radiographic interpretation

18. Different types of Pulp therapy:
1- Deciduous teeth:
•Indirect pulp capping.
•Direct pulp capping.
•Pulpotomy.
•Pulpectomy.

19. 2- Young permanent teeth:
•Indirect pulp capping.
•Direct pulp capping.
•Pulpotomy/ apexogenesis.
•Apexification.

20. Vital pulp therapy
 Pulp capping:
to maintain pulp vitally by placing a suitable
dressing either directly on the exposed pulp
(direct pulp capping) or on a thin residual
layer of slightly soft dentine (indirect pulp
capping).

21. Indirect pulp capping
Indirect pulp capping is used when the
tooth has a deep carious lesion. It may be
successful in the primary dentition
provided that the seal of the restoration is
intact.

22. Indication:
History:
Absence of spontaneous pain.
Clinical examination:
1. Large carious lesion in close proximity
to pulp.
2. absence of lymphadenopathy .
3. normal color of tooth .

23. Radiographs:
1. Normal periodontal ligament space
and lamina Dura .
2. No interradicular or per apical
radiolucency .

24. Contraindication:
History:
a. prolong spontaneous pain and
nocturnal tooth aches.
b. sharp pain that persist after remove
the stimulus.
Clinically :
a. excessive tooth mobility.
b. tooth discoloration .
C. non responsiveness to pulp testing
technique.

25. Radiographic :
a. large carious lesion with apparent pulp
exposure.
b. interrupted or broken lamina Dura .
c. widened periodontal ligament space.
d. radiolucency at the root apices or
interradicular area.

26. Technique:
 1. Remove caries
 2. Clean the area.

27.  3. Place Calcium
Hydroxide
 4. Place Zinc Phosphate
cement
 5. Permanent restoration or steel crown.

28. Direct pulp capping
Direct pulp capping is the procedure of
covering the exposed vital pulp by a
material which promotes healing of the
vital pulp tissues.
 Pulp capping is not recommended if the
diameter of the exposure is greater than a
pin-point.

29. Indications:
 They should be limited to traumatic
exposure during cavity preparation
(mechanical exposure).
 Small pin point exposure surrounded by
sound dentine.
 Mechanical or carious exposures in
asymptomatic vital young permanent teeth.
 Recent exposure.
 Vital pulp free from infections.

30.  No bleeding at the exposure site or an
amount that would be considered normal.
 Normal radiographic findings.

31. Contraindications:
 Cariously exposed deciduous teeth
 The diameter of the exposure is greater
than a pin-point
 There is a history of spontaneous pain.
 There is more than gentle bleeding from the
exposure site.

32.  Pathologic mobility.
 Pus or exudate from the exposure site.
 Fistulaswelling.

33. - Technique
 Isolate the tooth
 Prepare cavity in normal way, remove deep
caries, gently with excavator, and clean the
area. First removing peripheral caries, then
proceeding towards the pulp
 A non-irritating solution such as normal
saline or chloramines should be used for
irrigation of the exposure sites before
placement the capping material

34. Calcium hydroxide is the material of
choice of capping exposed vital pulp
tissue. When placed,
the material should not be
forced into the exposure site
 Zinc oxide-eugenol is placed over the
calcium hydroxide layer as sealant then
zinc phosphate cement and the
permanent restoration is inserted at the
same appointment.

35. N.B: Direct pulp capping is generally
contraindicated for 1ry teeth because:
 Pulpal inflammation usually persists,
increased cellular content, & results in total
pulp necrosis or internal resorption, this by
transforming of these cells into odontoclast
and stimulation of osteoclast.
 Rapid spared of inflammation throughout
the primary coronal pulp , due to increased
blood supply.