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Presented by Prof. Dr. Nevine Waly Prof. in Pediatric Dentistry and Public Health Department Faculty of Oral and Dental Medicine Cairo University
Pulp exposure is caused most commonly by caries but may also occur during cavity preparation or by fracture of the crown. Pulp exposures caused by caries occur more frequently in primary than in permanent teeth because primary teeth have relatively large pulp chambers, more prominent pulp horns and thinner enamel and dentine. In primary molars with proximal cavities, pulp involvement occurs in about 85% of those with broken marginal ridges.
diseased pulp or involvement of periodontal ligament. Sensitivity to percussion indicates apical or periodontal inflammation or both. Presence of swelling, sinus, draining fistula or chronic abcess indicates a non vital pulp.
bleeding are the most valuable observations in diagnosing the condition of the primary pulp:
Small pin-point exposure surrounded by sound dentine indicates favorable pulp condition. Large exposure with watery exudate or pus indicates unfavorable pulp condition. Small controllable amount of bleeding during and or following pulp amputation is a favorable condition for pulp therapy. Excessive uncontrollable bleeding during and or following pulp amputation is an unfavorable condition for pulp therapy.
3-Radiographic interpretation:
Radiographic interpretation in children is
more difficult than adults due to:
Young permanent teeth with incompletely formed root ends give the impression of Periapical radiolucency. The roots of primary molars undergoing normal physiologic resorption may suggest a pathologic change. Permanent teeth are superimposed on the primary teeth.
4-Vitality tests:
Either thermal or electrical. Thermal pulp vitality tests: Application of heat (hot gutta percha or hot instrument). Application of cold (ethyl chloride or ice cone). The reaction of a normal tooth is tested first (pain disappears after removal of stimulus). If pain persists, this indicates pulpitis. If tooth does not respond, this indicates a nonvital pulp.
Electric pulp tester: Record the reading of a normal tooth first. If the affected tooth responds at a lower reading, this indicates hyperemia or pulpitis. If the affected tooth responds at a higher reading, this indicates pulp degeneration. Disadvantages of electric pulp tester: Child may become apprehensive and gives false response. Gives false positive response when content of pulp is liquid (liquifaction necrosis).
Technique:
First visit: Administer local anesthesia and isolate tooth with rubber dam. Preoperative appearance of a deep lesion close to pulp in an asymptomatic vital tooth. Gross caries is excavated, while soft dentine in the deepest portion is left and covered with calcium hydroxide paste and a temporary dressing. Tooth should not be re-entered for 6-8 weeks. During that time the soft caries becomes harder and calcium hydroxide will stimulate the formation of secondary dentine and the remaining microorganisms will be destroyed by bactericidal action of calcium hydroxide.
Second visit: The tooth is reopened and remaining caries is carefully removed. Sound dentine is apparent which protects the pulp. Apply calcium hydroxide dressing and restore the tooth. If a small exposure is encountered a different type of treatment is provided.
Technique:
Administer local anesthesia and isolate tooth with rubber dam. When pulp is exposed during the last stages of caries removal, carious dentine chips will be pushed into the pulp tissue which becomes contaminated resulting in pulpitis. So enlarging the exposure site is needed to wash away carious fragments and allow direct contact of capping material with pulp tissues. Flush the cavity with noraml saline and dry the area. Cap the pulp with calcium hydroxide followed by zinc oxide eugenol then zinc phosphate cement and the permanent restoration. N.B. Direct pulp capping is not encouraging in primary teeth because pulp tissue ages early and less active undifferentiated mesenchymal cells are available. Also, during Process of root resorption, cells may transform to odontoclasts causing internal resorption.
Pulpotomy
Definition: It is the removal of coronal pulp tissue till the level of enterance of pulp canals and capping the radicular pulp tissue to keep it in a good condition. Indications: In primary and young permanent teeth with wide pulp exposures when the tissues adjacent to exposure site show slight evidence of inflammation. Slight amount of bleeding at exposure site which is considered within normal. Normal clinical and radiographic signs.
Types: According to the capping material used: -Calcium hydroxide pulpotomy. -Formocresol pulpotomy.
Formocresol pulpotomy: There are two methods: -One visit technique. -Two visits technique
Administer local
Amputate coronal
pulp tissue till enterance of root canals with sharp spoon excavator or large round bur at low speed.
cotton pellet moistened with water placed over amputated pulp stumps for 3 minutes. When bleeding is arrested, apply a cotton pellet moistened with formocresol for 3-5 minutes. Pulp stumps appear dark brown (fixed by formocresol).
stumps with zinc oxide eugenol paste, fill pulp chamber with temporary cement and prepare the tooth for chrome steel crown. N.B. Success rates up to 98% have been reported using pulpotomy technique in vital primary teeth.
Preoperative
Postoperative
Pulpectomy
Partial pulpectomy: Definition: It is the removal of coronal pulp tissue and as much as possible of the contents of root canals without interfering deeply into the apical portion. Indications: It is indicated in primary molars (due to difficulty of performing complete pulpectomy because of difficulty to obtain adequate access to root canals in the small mouth of children and due to the morphology of root canals such as lateral brancings and ramifications and presence of accessory root canals in primary molars where removal of all radicular pulp content is impossible). When the coronal pulp tissue and the tissue entering the root canals are vital but show clinical evidence of hyperemia . The tooth may or may not have a history of pain. Normal radiographic findings.
Technique:
with rubber dam. Remove all caries and roof of pulp chamber and amputate coronal pulp tissue. Remove all accessible radicular pulp tissue with hedstrom files or barbed broaches. File the canals to the resistance point. Usually the file stops at curvature in apical 1/3 of root.
paper points. Apply cotton pellet with formocresol for 3 minutes to fix remaining pulp tissue. Coat the walls of canals with creamy zinc oxide eugenol paste using the last file or paper points. Fill canals with stiffer mix of zinc oxide eugenol [ rolled into a point and condensed with root canal plugger ]. Fill pulp chamber with temporary cement and prepare tooth for chrome steel crown.
Second visit:
Remove cotton pellet and place antiseptic
paste [ eugenol, formocresol and zinc oxide powder ] . Press antiseptic paste into root canals with a cotton pellet. Pressure forces the paste down the root canals . Restore the tooth in usual manner. N.B: This technique could be used in the presnce of sinus , abcess or some degree of tooth mobility. A sinus is expected to disappear following control of infection and a mobile tooth becomes firm as periapical bone reforms .
Etiology: All capping materials are irritating and produce some inflammtion , inflammatory cells attract osteoclasts which initiate internal resorption. Because the roots of primary are undergoing normal physiological resorption there is osteoclastic activity in the area which predisposes the tooth to internal resorption.
2-Alveolar abcess:
Develops several months following pulp
therapy. Infection may be present in bone around root apex or more commonly in bifurcation area. May be associated with fistula in chronic conditions.
Pulp therapy for young permanent teeth Apexogenesis [ vital pulpotomy ]: Indications: Vital permanent teeth with immature root development having large carious or traumatic exposures. Aim: Maintain the radicular pulp vital to allow complete root development. Calcium hydroxide placed over radicular pulp stumps stimulates the formation of a calcific bridge and successful root closure.
sweetened liquid is pooled around the maxillary anterior teeth.Acidogenic bacteria produce acids. Salivary flow is decreased during sleep, so the clearance of the liquid from the oral cavity is slowed.
Clinical picture:
Clinical picture: 1-Teeth affected:
The four maxillary incisors are most affected. The four mandibular incisors usually remain
sound because the tongue lies over the lower teeth during sucking. The other primary teeth may show caries depending on how long the carious process remains active.
2-Clinical pattern:
The maxillary incisors develop a band of
dull white demineralization along the gum line that goes undetected by parents. Then the white lesions develop into cavities that circle the necks of teeth with a brown or black collar. In advanced cases the crowns of the four maxillary incisors may be destroyed completely leaving decayed brownish black root stumps.
Management
A-Prevention: National educational programs for mothers to influence their dietary habits as well as those of their infants. Water fluoridation. Early dental examination at or before the age of one year. Parents counseling: From birth, the infant should be held while feeding. The child who falls asleep while nursing should be burped and then placed in bed. The mother should wean the child as soon as he can drink from a cup at approximately 12-15 months of age. Avoid prolonged and frequent infant feeding habits. Professional application of topical fluoride. Development of appropriate dietary and oral hygiene habits at home.
B-Treatment: Cessation of habit. Sealing all caries free pits and fissures. Fluoride application. Gross excavation of carious lesions and filling cavities with re-enforced zinc oxide eugenol or glass ionomer cement to arrest caries and prevent its progression to the pulp. Pulp therapy and restoration of teeth.