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8/8/2019 Pulp Dental Students 07
1/22
Pulp Therapy in Pediatrics
Primary and Young Permanent Teeth
Robert J. Feigal, DDS, PhD
Professor
Pediatric Dentistry
Pulp Therapy in Pediatric
Why ? When ?
How ?
Kids are Great PatientsKids come in a variety of sizes and they
arrive with a range of disease
Most show little decay and are atgenerally low caries risk
Nice Kid -- Check His Smile
Some appear fine --
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This is a Serious Bacteriological Infection
Complete with Systemic Effects
But on closer examination are in real troubleA few are in REAL TROUBLE
Complete pulpal necrosis of primary molars and periapical infection
Non-restorable molars
Draining
abscesses
4 Year Old Patient
Traumatic Injury Directly Involving the Pulp Tissue
While others find trouble that is not disease
Traumatic Injury Directly Involving Pulp Tissue
Why Pulp Therapy ? Pulp tissue is alive and functioning
Surrounded by the hard
structures of teeth
It, in fact, has produced much
of that very hard structure It can produce more hard
structure as a defense system -
part of inflammatory response
It provides nutrients and
innervation to the pulpal-dentin
complex
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Odontoblasts and Ameloblasts
Hard at work
Secreting pre-enamel and
pre-dentin matrices
Early Dentin and Enamel
Pulpal cell
response --
Inflammatory cells
Odontoblasts
producing more
dentin
A Pulp Under Severe Stress Why Pulp Therapy ? Pulp tissue is alive and
functioning Pulp has the potential to produce
a robust inflammatory response toirritation / infection
By its inflammatory responses, italso produces pain for the patient
Pulp tissue can break down andbecome necrotic
Infection / inflammation canspread throughout the pulp tissue
and out the tooth to thesurrounding tissues
First permanent molar
with deep caries and
incomplete root
formation
Same tooth
18 months later --
reparative dentin
and complete roots
Why Pulp Therapy ? Pulp tissue is alive and functioning
Therefore, the pulp tissue requires carefulprotection in all that we do in dentistry to
avoid the negative responses and toencourage the positive ones.
This affects diagnostic decisions,restorative decisions, prep designs,methods of preparation, materials used.
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Levels of Pulp Therapyin Primary Teeth The Range of Pulp Therapy
1990
1. Indirect Pulp Capping
2. Direct Pulp Capping
3. Vital Pulpotomy4. Pulpectomy
1. Rarely suggested for primary teeth
2. ZOE fill
The Range of Pulp Therapy2000
Indirect Pulp Therapy
Direct Pulp Capping
Partial Pulpotomy - Cvek Pulpotomy
Pulpotomy
Pulpectomy
Commonly suggested in primary teeth
Ca(OH)2 fill or Iodoform-Ca(OH)2 mixes
Levels of Pulp Therapyin Primary Teeth
The level of
therapy depends
upon the level of
injury or disease,
Therefore, careful
diagnosis is vital
Pulp:Diagnosis, then Therapy
What do signs and symptoms tell us ?
What influences your diagnoses ?
How precise can you be ? What does it matter anyway ?
Often in Endodontic thinking, it is an
all-or-nothing decision,
i.e. Pulpal inflammation, yes RCT
In Pediatrics this is a more subtle choice
A Continuum of Care driven by Symptoms
Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.
(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
(Xray) (Fistu.)
Symptoms
Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
TreatmentRestore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext
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A Continuum of Care driven by Symptoms
Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis- PA involv.
Caries in dentin does affect pulp
Enamel
Dentin
Pulp
M/O in
Dentin
Early inflam
response
Radiographic Signs of Caries Into the Pulp and Necrosis
Caries Size, Shape, and Proximity
Inter-radicular and
Periapical Boney Changes
Clinical presentation
After caries removal
and pulp chamber
opening
A Continuum of Care driven by Symptoms
Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.
(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
(Xray) (Fistu.)
Symptoms
A Continuum of Care driven by Symptoms
Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.
(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
(Xray) (Fistu.)
Symptoms
Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
TreatmentRestore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext
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Deep Caries Into the Pulp Deep caries without Pulpal Exposure
A Continuum of Care driven by Symptoms
Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.
(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
(Xray) (Fistu.)
Symptoms
Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
TreatmentRestore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext
A Continuum of Care driven by Symptoms
Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.
(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
(Xray) (Fistu.)
Symptoms
Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
TreatmentRestore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext
A Continuum of Care driven by Symptoms
Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.
(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
(Xray) (Fistu.)
Symptoms
Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
TreatmentRestore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext
Levels of Pulp Therapyin Primary Teeth
The level of
therapy depends
upon the level ofinjury or disease,
Therefore, careful
diagnosis is vital
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Pulpal Diagnosis How does this work with children ?
Different communication skills Need for parental input
Questionable use of objective tests
Methods of Pulp Diagnosisin Children
Clinical signs Patient reported symptoms
Radiographic signs
Hot / Cold stimulation **
Electronic pulp testing **
Pulpal Diagnosis
Reports of Pain Is it spontaneous ?
Or
Is it pain that is stimulated ?
Question to parents: Does your child wake up from sleep
because of tooth pain
Why the Pain Questions ?
Early in the caries process, eating sweetsor chewing on food can cause pain
This tooth may well be treated by restorationwithout involving entering the pulp
But only late in the process, when the pulpis irreversibly involved does one findspontaneous pain.
At this point, entering the pulp and correcttherapy of the tissue is necessary
Pulpal Diagnosis
Reports of Pain
Is it spontaneous ?
OrIs it pain that is stimulated ?
Question to parents:
How long has this been going on?
Pulpal Diagnosis
Clinical observations
Hard tissue signsSoft tissue signs
Physical manipulations Mobility
Pain to percussion
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Complete pulpal necrosis of primary molars and periapical infection
Non-restorable molars
Draining
abscesses
4 Year Old Patient
Pulpal Diagnosis
Radiographic diagnosisExtent of caries
Depth
Shape
Proximity to pulp
Boney changes Inter-radicular radiolucency
Peri-apical radiolucency
Pulp shape changes
PDL signs
Radiographic Signs
Deep dentin
caries
Dentin
cariesEnamel
caries
Radiographic Signs
Abscessed tooth
PA infection
Radiographic Signs
Internal
resorption
Inter-radicular
radiolucency
A Continuum of Care driven by Symptoms
Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.
(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
(Xray) (Fistu.)
Symptoms
Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
TreatmentRestore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext
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Pulp Tissue Biology
New concept of leaving some caries
behind, in order to stay out of pulp andallow a normal healing process.
1. Indirect Pulp Therapy
A new take on an old treatment
2. Atraumatic Caries Treatment (ART)
3. Sealing in early dental caries
Indirect Pulp TherapyEvolution of a Method
(1960s) Minimal, hard caries left behind plus
re-entry for full removal
(1980s) Minimal caries left behind and
no re-entry
(1990s) Major caries left behind
IPT: Evolution of a MethodEarly Literature:
Massler, 1955 J Tenn D A 35: 399
King, 1965 Oral Surg 20: 633
Aponte, 1966 J Dent Child 33: 164
Frankl, 1972 Oral Surg 34: 293
Sawusch, 1982 J.A.D.A. 104: 459
Newer Literature:
Fuks, 1991 Curr Op Dent 1: 556
Bjorndal, 1997 Caries Res 31: 411
Leksell, 1996 End Dent Tr 12: 192
Farooq, 2000 Pediatr Dent 22: 278
Al-Zayer/ Krusky, 2001 UMich T heses
Weesheijm 1999 Caries Res 33: 130
Falster, 2002 Pediatr Dent 24: 241
Vig et.al 2004 Pediatr Dent 26:214
Related Literature:ART 1990-2004
Mertz-Fairhurst 1998 J.A.D.A. 129: 55
Remove Infected Dentin,
Leave Affected Dentin
Indirect Pulp Therapy
Deep Caries,
but No Symptoms
of Pulp Pathology
Evidence of Healing
i.e. Dentin Formation
or Root end Closure
Indirect Pulp Therapy
Indications
Tooth with gross caries but no spontaneous painsymptoms
No evidence of PA or IR pathology on radiograph
Restorable tooth
Healthy child -- no immune system compromise
Indirect Pulp Therapy
Procedural Steps
Careful diagnostic procedures
Profound anesthesia
Rubber dam isolation Removal of infected dentin - stop before
entering pulp
Critical cleaning of enamel-dentin junction
Placement of calcium hydroxide at deepest
Seal the dentin with GIC base material
Restore with a material that seals margins
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2001 - Over 90% success in primary and permanent teeth.
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First permanent molar
with deep caries and
incomplete root
formation
Same tooth
18 months later --
reparative dentin
and complete roots
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Direct Pulp Capping
Indications
A clean, small exposure of the pulp Exposure shows no signs of inflammation
No symptoms of pain
Healthy tooth
Healthy patient
Direct Pulp Capping
Procedural Steps
Careful diagnoses
Profound anesthesia
Isolation
Gently rinse the exposure site
Cover the exposed pulp with calciumhydroxide or MTA
Place a bonding base on the surrounding
dentin Restore the tooth
Partial Pulpotomy
Indications
A small and clean exposure of pulp
Ideally, a traumatic fracture causing the
exposure
No previous signs or symptoms of pathology
Healthy patient without immune systemcompromise
Partial Pulpotomy Procedural Steps
Careful diagnoses
Profound anesthesia
Isolation
Use a small, clean round bur to remove about 2 mmof pulp tissue at the exposure site
Hemostasis by most gentle means, saline or LA rinseis best
Placement of a layer of calcium hydroxide or MTA
Bonded base over the remaining dentin
Protection with bonded composite resin
Restore the tooth to full esthetics and function
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Cvek Partial Pulpotomy
Perfect for Trauma Cases
Excellent Long Term Success Local area pulpotomy with Calcium
Hydroxide
Success even with hours and days ofexposure !
Anterior trauma
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Gentle placement of calcium hydroxide ontothe pulp
Protection of remaining dentin
Etching for the esthetic restoration Bonding agent placement
Early composite resin coverage Completed composite resin coverage
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Radiographic follow-upMajor reasons to use the
partial pulpotomy method
It recognizes the limited inflammatoryreaction to the pulp in some clinicalcircumstances
It recognizes the healing potential of thepulp when challenged in a limited way
It allows the best chance for pulpalmaturity, completion of dentin formation,and root end closure -- leading to
long-term root and crown strength
Pulpotomy
Indications
Tooth with symptoms of deep decay andshort-term spontaneous pain
No pain to percussion
No radiographic signs of PA or IR pathology
Restorable tooth
Patient with compliant behavior
Healthy patient -- no immune system
compromise
Pulp Exposure During Prep Second primary molar with deep caries, symptoms,but no signs of full pulpal necrosis or PA pathology
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Second primary molar -- 4 years post pulpotomy Post pulpotomy -- normal time of resorption
Hard Tissue SignsAfter Initial Preparation
Access Opening and TissueRemoval
Seating the SSC Crownsover Pulpotomy
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Newest Data Published
Vig, Coll, Shelton, and Farooq (Univ Maryland)
Caries Control and Other Variables Associated withSuccess of Primary Molar Vital Pulp Therapy.
Pediatr Dent 26: 214-220, 2004
Success
Overall Primary 1st Primary 2nd
FP 70% 61% 83%
IPT 94% 92% 98%
Pulpectomy
What is the traditional stance on
pulpectomy?
What has changed?
What are the newest data?
Recent Thesis
Steven Rayes
An Evaluation of Pulpectomies UtilizingVitapex root canal filling material in PrimaryAnteriors and Molars: A Retrospective Study
December, 2003
Alaska study 85% over 0.5 to 4.9 years
Signif effects of: radiolucency, type ofrestoration, and treatment location
Vitapex Success > ZOE Success
Intern. J Paediatric Dent, 2004
Mortazavi and Mesbahi, Comparison of zinc oxide eugenol andVitapex for root canal treatment of necrotic primary teeth
52 teeth, followed up to 16 months
ZOE Vitapex
Success 78% 100%
Pulpectomy Procedural Steps
Diagnostics
Profound anesthesia
Rubber dam isolation
Prep for restoration
Caries removal Access opening into pulp chamber
Pulp extirpation -- barbed broaches
Physical cleaning of canals -- files
Rinsing with sodium hypochlorite solution
Dry canals
Inject with calcium hydroxide plus iodoform paste
Place base over paste
Restore with full coverage -- SSC
DiaDent Vitapex from:
DiaDent Group International, Inc 604-451-8851
Calcium Hydroxide Paste with Iodoform
Antibacterial
Readily resorbable
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Finish with Full Coverage Longevity of SSC is twice that of any
intra-coronal restoration
Why ? Extent of physical damage to the tooth results
in weakness
Pulpectomy results in tooth structuredehydration and eventual brittleness
Need for a complete seal from the oral cavity
High caries risk patient can benefit fromhaving the other tooth surfaces covered and
free from recurrent decay
How about Extraction as a Pulp Therapy ?
Extraction
Indications
Non-restorable tooth
PA and/or Inter-radicular pathology
Soft tissue swelling or draining fistula
Tooth with limited long-term value
Limited patient compliance
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