2011/06/03

PULP THERAPY I

DX OF PULP PATHOLOGY

Thorough Dx NB! History (Pain? Symptoms?) Clinical exam Radiographs Vitality tests
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D r. N. Mo ham ed , 2 01 1

HISTORY OF PAIN
Unreliable Momentary pain- triggered by pH/ temp - lost restoration - mild symptoms - reversible (vital pulp) Pain (eating)= food impaction? Persistent- cont. after removal of stimuli Spont- occurs in absence of stimuli - child woken by pain

CLINICAL EXAM

Pulp Rx

Gumboil= non-vital Xtr/ pulpectomy Mobility Normal?/ Pathologic?(exfoliation times) Sensitivity to percussion?= high rest?/pulpal inflammation? Cellulitis antibiotics
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CELLULITIS (ANTIBIOTICS)

RADIOGRAPHS/ X-RAYS

Spot Pathology= NB!! Know what is normal!! Proximity of caries to pulp Radiolucencies Int/ ext. resorption Bone loss Pulpal calcifications
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pulpect/ Xtr

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VITALIT Y TESTING

PULP RX OTHER FACTORS TO CONSIDER

Physical cond: -- pts/ immune comprom. NB!! NO PULP THERAPY (rather xtr + ABs) Haemophiliacs?? Can tooth be restored? SSC/ Xtr + space maintainer? Cooperation Normal exfoliation times Overall caries activity (Plan A/B)
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Unreliable in children (dont explain sensation) Recently erupted teeth/ shortly after trauma false negative/ can test non-vital Test adjacent/ contralateral teeth

CLASSIFICATION OF PULPAL CONDITIONS

Class I pulp
Asymptomatic vital

CLASS III PULP

Class II pulp
reversible pulpitis (mild) carious lesion/ leaking rest. Rx:
remove caries place restoration (adequate lining)
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irreversible pulpitis (severe) spontaneous pain pain worse at night heat = pain

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CLASS III PULP

Rx

CLASS IV PULP= NON-VITAL/ NECROTIC

Rx

Permanent tooth

Primary tooth

RCT

iii (a) pulp

iii (b) pulp

Permanent tooth

Primary tooth

Normal, bright red blood

Little/ no blood

PULPOTOMY

PULPECTOMY
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RCT (GP)/ Xtr

Pulpectomy (2 visit)/ Xtr

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PULP THERAPY RX OPTIONS

1 . IPC/ IPT

IPC/ IPT Direct pulp capping Pulpotomy Pulpectomy

Vital

Non-vital

When? Prim/ perm tooth asymptomatic (Class I/ II pulp only) very deep carious lesion (close to pulp) Why? Avoid pulpal exposure/ preserve vitality
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How?

HOW

IPC/ IPT (CONT)

1. LA 2. Remove lateral caries 3. Remove infected caries over pulpal area (leave affected dentine) 4. SnF 2 (optional) 5. Ca (OH) 2 6. Temp
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7. Leave for 6-8 weeks arrest deepest caries 8. Repeat if necessary 9. Hard dentine surface permanent restoration NB!!** 1 tooth IPT use of Conv. GI no replacement/ re-entry
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2. DIRECT PULP CAPPING

DIRECT PULP CAPPING (CONT) How?

Permanent tooth Primary tooth NB!! NEVER DIRECT PULP CAPPING

When? small exposure (trauma/ mechanical exposure) 2 teeth only asymptomatic tooth NB!! Exposed only a few hrs NB!! NOT CARIOUS EXPOSURE!!!
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Ca (OH) 2 / Dycal/ Life placed over pulpal exposure

Always PULPOTOMY
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PULPOTOMY

PULPOTOMY

Definition: Surgical removal of entire coronal pulp Leave vital radicular pulp within canals intact

Purpose:

Treat affected nerve of tooth tooth can still be saved Maintains space and function

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PULPOTOMY: INDICATIONS (1 0 TEETH)

PULPOTOMY: CONTRAINDICATIONS (1 0 TEETH)

Class I, II or III (a) pulp only Bright red blood upon pulpal exposure (vital)

Dark/ no blood upon exposure = non-vital (gumboil) Uncontrolled bleeding Swelling/ cellulitis Marked tenderness to percussion Mobile tooth (pathologic)
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PULPOTOMY CONTRAINDICATIONS (CONT)

PULPOTOMY TECHNIQUES

Int. resorption Dystrophic calcifications/ pulp stones Radiolucencies in furcal/ periradicular areas Tooth not restorable Immune comprom. pts
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Different pulpotomy techniques

Devitalization

Preservation

Regeneration

FC electrocautery

Ferric sulfate Gluteraldehyde

CH BMP Freeze-dried bone MTA Biodentine?

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BASIC (VITAL) PULPOTOMY TECHNIQUE

PULPOTOMY TECHNIQUE (CONT)

1. LA 2. Remove lateral caries (before pulp exposure) 3. Remove ENTIRE roof of pulp chamber 4. Remove contents of pulp chamber
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5. Medicament (FC/ lasers/ electrocautery, gluteraldehyde, FS) 6. ZnO eugenol 7. Ag

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NEXT WEEK (PART II)

HANDOUTS

Different medicaments Detailed techniques for pulpotomy and pulpectomy procedures

The object of handouts is to provide a background of information which is to be augmented by wider reading around the topic. Notes are not intended as a substitute to attending the lecture.

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