Pulp Treatment Nakabeh

8/2/2019 Pulp Treatment Nakabeh

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Management of the grossly carious primarymolar is a common but sometimeschallenging aspect of dental care for youngchildren

The first treatment decision for the youngpatient with one or more extensively cariousprimary molars is whether to retain or extract

these teeth


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Diagnosis

The dental problems must be assessed beforea treatment plan is designed

It is important to try to provisionally diagnose

the likely pulpal status of the toothconcerned,

Clinical signs and symptoms

Special investigations


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Clinical signs andsymptomsThe following symptoms and clinical signs are

likely to be associated with significant pulpalinflammation and pathology:

Any history ofspontaneous severe pain,particularly at night

Reported pain on biting

The necessity for analgesics


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Clinical signs andsymptoms The clinical extent of the caries, notably the

presence of marginal ridge breakdown


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symptoms

The presence of any intra-oral swelling orsinus

A history of intra-oral or facial swelling


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Special investigations

1 Gentle finger pressure may determinewhether the tooth is mobile or tender

2 Pulpal sensibility testing is notappropriate for primary molars


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Special investigations3 Radiographs are mandatory to provide

information about

The extent of the caries and the proximity to

pulp horn

Presence of any periradicular pathology

Degree of pathological or physiological root

resorption

Presence of a successor


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Bitewing


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Periapical


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Indications for pulptreatment

Medical factors Patients at risk from an extraction (e.g.

bleeding disorders, hereditary angio-oedema)

Patients at risk if a general anaesthetic is

required for tooth removal (e.g. cystic

fibrosis, muscular dystrophies)


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Indications for pulptreatmentDental factors Minimal number of extensively carious

primary molars likely to require pulp therapy(


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Indications for pulptreatment

Social factors A regular attender, with good compliance

and positive parental attitudes


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Indications for tooth extraction

Medical factors Patients at risk from residual infection

(e.g. immunocompromised,susceptibility to infective endocarditis)


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Dental factors Tooth unrestorable after pulp therapy

Extensive internal root resorption Large number of carious teeth with likely

pulpal involvement (>3)


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Tooth close to exfoliation (>2/3 root resorption)

Contralateral tooth already lost (in the case of

a first primary molar, and if indicated

orthodontically)

Extensive pathology or acute facial swelling

necessitating emergency admission


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Social factors An irregular attender, with poor

compliance and unfavourable parentalattitudes.


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Extraction and replacementwith a prosthesis


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Local Anesthesia

Surface anaesthesia

Injection


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Topical anaesthesia

Sprays

Solutions

Creams

Ointments

Lidocaine 5% cream

Benzocaine 20% cream


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Topical


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1. Dry area of application

2. Anaesthetic applied over a limited area

3. Anaesthetic applied for sufficient time


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L.A Techniques

Infiltration anaesthesia

Inferior alveolar nerve block

Intrasseous

Intra-ligamental

Interseptal


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Maxillary infiltration

0.5 to 1.0 ml is sufficient for pulpalanaesthesia of most teeth in children

Onset of pulp anesthesia: 3-5 min

Duration :30-60 min


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IAN block

Introduce the short needle from theprimary molars of the opposite sideand syringe held parallel to the

mandibular occlusal plane

Point of insertion about 5mm above

the mandibular occlusal plane


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Onset of pulpal anesthesia: 10-15 min

Duration: 90 min and sometimes up to2.5 hours


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Rule of 10Age of patient + number of the tooth

If < 10 infiltration has a goodchance of working

If 10 infiltration not enoughalternative

Examples8 year + (D) 4 = 12

4 year + (D) 4 = 8


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Interseptal

Deposition of LA in porous alveolar bone(base of the interdental papilla)

Minimal soft tissue anaesthesia

Minimum amount of anaesthesia required

Leakage of LA solution (taste)


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Interseptal


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Interseptal

Apply pressure and advance further 1 2 mm

0.2-0.4 ml in 20 sec

Blanching


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Intraligamental

Also called periodontal ligament anaesthesia

Old technique 1912 to 1923 in localanaesthetic books


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Technique

Insert a 27 or 30 gaugeneedle at ~ 30 degreesto the long axis of the

tooth into the gingivalsulcus

mesial and distal of thetooth

Advance needle untilthere is firm resistance


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Technique

Do Not inject too quickly (15 sec perdepression)

Wait 15 sec after injection before removeneedle

Onset is rapid

Duration of pulpal anesthesia 10-20 min

Ad t f


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Advantages ofIntraligamental Localized area (one tooth) without

extensive soft tissue anaesthesia

Minimal amount of anaesthesia used 0.2mlper root

Rapid onset

Alternative to block


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2 % lidocaine 1:100,000 epinephrine

=2 gm/100ml= 2000mg/100ml=20 mg/ml

=1gm/100000ml=1000mg/100000= 0.01mg/ml

A ti i 4%


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Articaine 4%


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Ubistesin 1/200 000 solution for injection

For routine-type interventions during minor procedures

Articaine 4%

Epinephrine (Adrenaline) 1:200000

Ubistesin 1/100 000 solution for injection (Ubistesinforte)

For complicated procedures requiring prolonged anaesthesiaArticaine 4%

Epinephrine (Adrenaline) 1:100000


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Buccal infiltrations of articaine with epinephrinedid not differ in their efficacy in obtaining pulpalanesthesia for mandibular permanent first

molars.Ian P. Corbett et al :Articaine Infiltration for Anesthesia of Mandibular First

Molars JOE Volume 34, Number 5, May 200


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Pulp of primary teeth

Relatively larger

Pulp horns are closer to the outer surface

Great variation in size and location

Mesial pulp horn is higher

Pulp chamber shallow

Form of the pulp follows the external anatomy

Usually a pulp horn under each cusp

T t t ti i i


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Treatment options in primaryteethIndirect pulp capping

Used in case of deep carious lesion(class I) approximating the pulp without signs

and symptoms of pulp degenerationThe caries surrounding the pulp is left in place to

avoid pulp exposure and is covered with a

biocompatable material


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Materials

Calcium hydroxide should be followedby glass ionomer cement or reinforcedzinc oxide eugenol to prevent

microleakage since the calciumhydroxide has a high solubility, poor sealand low compressive strength

Dentine bonding agents Resin modified glass ionomer


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Indirect pulp capping should be followedby a good restoration that preventsmicroleakage

It is not necessary to reenter the primarytooth to remove residual caries afterindirect pulp capping as long as there is

a good seal and secondary dentineforms


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Advantages if IPC

Has a high success rate in long termstudies even higher than pulpotomy

Normal exfoliation time of teeth


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Direct pulp capping

It is not preferred in decidous teeth andhas a low success rate

Pulpal inflammation usually persists and

results in total pulp necrosis An exception is a small mechanical

exposure on vital symptom free tooth

which is already isolated with a rubberdam


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Pulpotomy

Indicated in cases of pulp exposure due tocaries removal or mechanical pulp exposurebut without radicular pathology

The coronal pulp is amputated and the rest ofradicular pulp is treated with a long term

clinically successful medicament


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materials

Buckleys solution of formocresol

Ferric sulfate

Gluteraldehyde

Electrosurgery

MTA

Others (BMP, collagen)


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Success rates

Formocresol and ferric sulfate have thesame long term success rates

The highest success rate was for the

MTA Electrosurgery, calcium hydroxide and

gluteraldehyde had a lower success

rates than FC and FS


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Concern over the use of formaldehyde

This resulted in the withdrawal of Buckleys

formocresol and all paraformaldehyde-

containing devitalising pastes from themajority of teaching hospitals.


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Buckleys formocresol

Tricresol 35%

Formaldehyde 19%

Glycerol 15%

Water 31%

A dilution of 1/5 th have been shown to be

as equally effective and less toxic


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A cotton pellet used with only a trace of FCon the pulp stumps for 5 minutes

Be aware not to touch the soft tissue it will

cause burns It causes fixation of the pulp tissue in

radicular pulp

Use reinforced zinc oxide eugenol as a basematerial directly over the pulp stumps


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Restore the tooth with proper restorativematerial (SSC, amalgam, compomer)

if bleeding does not stop then the radicular

pulp is inflammed and this indicates apulpectomy


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Ferric sulfate

It is an astringent, stops bleeding byagglutination of blood proteins to make a plugthat seals the blood capillaries

It promotes pulpal haemostasis throughchemical reaction with blood

It controls bleeding and forms a protective metal-protein clot over underlying vital radicular pulp


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Used in a 15.5% for 15 seconds on thepulp stumps to stop bleeding

Use glass ionomer as a base and not zinc

oxide eugenol It is considered to be a good substitute to

FC pulpotomy with the same success rate


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Pulpotomy should be checked for clinical andradiographic success after 6 months and thenyearly


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P l


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Pulpectomy

Indicated for teeth with irriversible pulpitis ornecrotic pulp

Difficult on molars due to tortuous and

irregular pulp canals Beware of tooth buds


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The canals should be debrided and irrigatedwith normal saline 0.9%, chlorhexidine solution0.4% or sodium hypochlorite solution 0.1%

Filling material used in the canals ( nonreinforced zinc oxide eugenol, iodoform paste

KRI, iodoform paste with non setting calciumhydroxide Vitapex or Endoflax)


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Then the tooth restored with a material toprevent microleakage

Clinical and radiographic evidence of success

should be checked after 6 months There should be no pathologic resorptoin or

radicular radioleucency and no signs of abcess

or sinus tract

Young permanent teeth


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Young permanent teeth

Vital pulp treatment for teeth diagnosedwith a normal pulp or reversible pulpitis

Treatment options:Indirect pulp capping

Direct pulp capping

Partial pulpotomyApexification


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Indirect p lp treatment


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Indirect pulp treatment

Used when the tooth has a deep cariesand is diagnosed with reversible pulpitisand in this case if all the decay is

completely removed endodontic therapywill be needed


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In the recent years the focus was to do itas a one step proceedure that is toremove the affected dentine as close as

possible to the pulp and use a protectiveliner, a base and a restorative materialthat prevents microleakage (no need toreenter the tooth again)

Two step technique (step wise


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p q ( ptechnique)

More recently a two step technique wasshown to be succesful in managingteeth with reversible pulpitis due to deep

caries and so the technique was revised

Step one


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Step one

Remove the carious dentine along the DEJ andonly excavate the outer most infected dentineleaving a carious mass over the pulp

This has the following objectives

1)Reduce the number of bacteria

2)Close the remaining caries from the biofilm in the

oral cavity3)Slow or arrest the caries development

Step two


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Step two

Wait for 3-6 months this is to allowprovisional diagnosis of pulp status and allowenough time for tertiary dentine formation

Reenter the tooth and remove the rest ofcaries (dentin will be darker, harder and dryresulting in shrinkage of the tissues leaving avoid under the restoration)

Do your final restoration

Critical for both steps


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Critical for both steps

Seal from microleakage

Follow up


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Follow up

Clinically no signs and symptoms

Radiographically normal tooth structure andmost important in immature teeth with open

apex is continued root development(Apexogenesis )


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Partial pulpotomy


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Partial pulpotomy

Used in immature permanent teethdiagnosed with normal pulp or reversiblepulpitis when there is exposure due to

caries or trauma

Proceedure


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Proceedure

Control the pulp bleeding using irrigation with abactericidal agent like sodium hypochlorite orchlorhexidine

Remove 1-3 mm (or more) below the exposuresite using a sterile high speed diamond roundbur with good cooling

The bleeding should be controlled in minutes ifnot then go deeper to remove inflamed pulptissue


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Cover the site with calcium hydroxide orMTA

The calcium hydroxide has a goodsuccess rate but the MTA has a morepredictable action

In case of MTA 1.5 mm thickness isused

Then cover with a layer of resin modifiedglass ionomer to ensure seal then thefinal restoration


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Follow up


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Follow up

Clinically no sign and symptoms

Radiographically continue rootdevelopment, no internal or external

resorption, no abnormal canalcalcification and no lesions

Non vital pulp treatment


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Non vital pulp treatment

Root formation not completed in immatureyoung teeth and this development of theroot will stop in case of pulp necrosis

and eventually tooth will be lost

Apexification


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Apexification

It is the process of inducing root endclosure of an incompletely formed non vitalpermanent tooth by removing the non vital

coronal and radicular pulp just short of theroot end and placing a biocompatiblematerial

Procedure


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Procedure

After removal of the necrotic pulp debris put anon setting calcium hydroxide dressing for 2weeks then irrigate and dry canal

Do not weaken dentine walls with too muchfiling

Take a WL and put your non setting calciumhydroxide and seal the tooth properly


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The apical seal takes 9-12 months to form You have to change the dressing every 3

months

Check your barrier with a paper point andradiographically

When the apical barrier has formed you can

obturate the canal with GP up to the level ofbarrier formation


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MTA composition


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MTA composition

Tricalcium silicate Dicalcium silicate

Tricalcium aluminate

Tetracalcium aluminoferrite

Gypsum

Bismuth oxide (to detect the material on

radiograph) The grey MTA contains iron

Procedure


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Procedure

Necrotic tissues should be removed fromcanal and it was suggested to use nonsettingcalcium hydroxide as an intracanal

medicament for 2 weeks After that irrigate and dry canal use the MTA

to make an apical barrier and plug it for 4mmat least using special MTA pluggers


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MTA needs 4-6 hours to set in humidconditions so seal tooth with a moist cotton

Next day obturate using GP and finish your

treatment

Necrotic Pulp regenerationi ll


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using stem cells

The canal disinfected without mechanicalinstrumentation but with copious irrigation with5.25% sodium hypochlorite

use of a mixture of ciprofloxacin, metronidazole,and minocycline (triantibiotic paste)

A blood clot was produced to the level of thecementoenamel junction to provide a scaffold

for the ingrowth of new tissue followed by adouble seal of mineral trioxide aggregate in thecervical area and a bonded resin coronalrestoration above it.


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Thank you

Pulp Treatment Nakabeh

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