PEDIATRIC DENTISTRY

“Treatment of pulpitis temporary and

permanent teeth in children.”

Lecturer: Dr. Katrin Duda

Pulp

From many perspectives, dental health is directly related to

the health of a unique tissue-that is, dental pulp.

However, the study of dental pulp is not restricted to

this tissue alone, but extends to its interactions with

many other tissues in health and disease. For example,

since dentin and pulp are anatomically and functionally

integrated, they are often referred to as the pulpodentin

complex.

Pulp

The pulp also interacts with other tissues

such as the periodontium and even the

central nervous system. Indeed, the

interrelationship between

dental pulp and other tissues is a major

theme in

the field of dentistry, in pulp biology

research,

and of course, in this textbook. It also

serves as a

rationale for the specialty of endodontics.

Pulp

According to one recent endodontics text, the purpose of

endodontic treatment is not to pre-serve the pulp but to

eliminate it, so as to remove those factors found in necrotic

and infected pulp that stimulate apical periodon-titis. 2 Thus,

the biologic rationale for nonsurgical endodontic treatment is

to manage the apical periodontitis that results from the

functional relationship between infected dental pulp and

apical tissue.

Pulp

Pulp

The dental pulp is the part in the center of a tooth

made up of living connective tissue and cells called

odontoblast. The dental pulp is a part of the dentin–

pulp complex (endodontium). The vitality of the

dentin-pulp complex, both during health and after

injury, depends on pulp cell activity and the

signaling processes that regulate the cell’s behavior.

Anatomy Pulp

Each person can have a total of up to 52 pulp

organs, 32 in the permanent and 20 in the primary

teeth. The total volumes of all the permanent teeth

organs is 0.38cc and the mean volume of a single

adult human pulp is 0.02cc. Maxillary central incisor

has shovel shaped coronal pulp with three short

horns on the coronal roof and triangular in cross

section. Canine has the longest pulp with elliptical

cross section.

Anatomy PulpThe large mass of pulp is contained within the pulp chamber of

the tooth. The shape of each pulp chamber corresponds

directly to the overall shape of the tooth, and thus is

individualized for every tooth; the pulp tissue in the pulp

chamber has two main divisions: coronal pulp and radicular

pulp. Crowns of the teeth contain coronal pulp. The coronal

pulp has six surfaces: the occlusal, the mesial, the

distel distal, the buccal, the lingual and the floor. Because

of continuous deposition of dentin, the pulp becomes

smaller with age. This is not uniform throughout the coronal

pulp but progresses faster on the floor than on the roof or

side walls.

Anatomy Pulp

Radicular pulp is that pulp extending

from the cervical region of the crown to

the root apex. They are not always

straight but vary in shape, size and

number. The radicular portion is

continuous with the periapical tissues

through.

Anatomy Pulp

Apical foraen is the opening of the radicular pulp

into the periapical connective tissue. The average

size is 0.3 to 0.4 mm in diameter. There can be

two or more foramina separated by a portion of

dentin and cementum by cementum only. If more

than one foramen is present on each root, the

largest one is designated as the apical foramen

and the rest are considered accessory

foramina. Most infections spread through the

apical foramen from the pulp to periapical tissue.

Anatomy Pulp

Accessory canals are

pathways from the

radicular pulp, extending

laterally through the

dentin to the periodontal

tissue seen especially in

the apical third of the

root. Accessory canals

are also called lateral

canals, because they are

usually located on the

lateral surface of the

roots of the teeth.

Anatomy Pulp

Development

The pulp has a background

similar to that of dentin,

because both are derived

from the dental papilla of

the tooth germ. During

odontogenesis, when the

dentin forms around the

dental papilla, the

innermost tissue is

considered pulp.

Structure of pulp

The central region of the coronal and radicular pulp contains

large nerve trunks and blood vessels. Has four layers :

Pulpal core, which is in the center of the pulp chamber with

many cells and an extensive vascular supply; except for its

location, it is very similar to the cell-rich zone.

Cell rich zone; which contains fibroblasts and undifferentiated

mesenchymal cells.

Cell free zone which is rich in both capillaries and nerve

networks.

Odontoblastic layer; outermost layer which contains

odontoblasts and lies next to the predentin and mature dentin.

Functions

The primary function of the dental pulp is to form dentin.

Other functions include:

Nutritive: the pulp keeps the organic components of the surrounding

mineralized tissue supplied with moisture and nutrients;

Sensory: extremes in temperature, pressure, or trauma to the dentin or

pulp are perceived as pain;

Protective: the formation of reparative or secondary dentin;

Formative: cells of the pulp produce dentin which surrounds and protects

the pulpal tissue.

Complications

Pulp acts as a security and alarm system for a tooth.

Slight decay in tooth structure not extending to the

dentin may not alarm the pulp but as the dentin gets

exposed, either due to dental caries or trauma,

sensitivity starts. The dentinal tubules pass the

stimulus to odontoblastic layer of the pulp which in

turns triggers the response. This mainly responds to

cold. At this stage simple restorations can be

performed for treatment.

Complications

 As the decay progresses near the pulp the response also

magnifies and sensation to a hot diet as well as cold gets

louder. At this stage indirect pulp capping might work for

treatment but at times it is impossible to clinically diagnose

the extent of decay, pulpitis may elicit at this stage. Carious

dentin by dental decay progressing to pulp may get fractured

during mastication (chewing food) causing direct trauma to

the pulp hence eliciting pulpitis.

Complications

The inflammation of the pulp is known as pulpitis.

Pulpitis can be extremely painful and in serious cases

calls for root canal therapy or endodontic therapy.

Traumatized pulp starts an inflammatory response

but due to the hard and closed surroundings of the

pulp pressure builds inside the pulp chamber

compressing the nerve fibres and eliciting extreme

pain (acute pulpitis). At this stage the death of the

pulp starts which eventually progresses to periapical

abscess formation (chronic pulpitis).

Complications

The pulp horns recede with age. Also with increased

age, the pulp undergoes a decrease in intercellular

substance, water, and cells as it fills with an

increased amount of collagen fibers.This decrease in

cells is especially evident in the reduced number of

undifferentiated mesenchymal cells. Thus, the pulp

becomes more fibrotic with increased age, leading to

a reduction in the regenerative capacity of the pulp

due its loss of these cells.

Complications

Also, the overall pulp cavity may be smaller by

the addition of secondary or tertiary dentin, thus

causing pulp recession. The lack of sensitivity

associated with older teeth is due to receded

pulp horns, pulp fibrosis, addition of dentin, or

possibly all these age-related changes; many

times restorative treatment can be performed

without local anesthesia on older dentitions.

Pulpitis

Pulpitis is inflammation of dental pulp tissue. The

pulp contains the blood vessels the nerves and

connective tissue inside a tooth and provides the

tooth’s blood and nutrients. Pulpitis is mainly caused

by bacteria infection which itself is a secondary

development of caries (tooth decay). It manifests itself

in the form of a thoothach.

Causes

Pulpitis may be caused by a dental caries that penetrate

through the enamel and dentin to reach the pulp, or it may be

a result of trauma, such as thermal insult from repeated

dental procedures. Inflammation is commonly associated

with a bacterial infection but can also be due to other insults

such as repetitive trauma or in rare cases periodontitis. In the

case of penetrating decay, the pulp chamber is no longer

sealed off from the environment of the oral cavity.

Causes

When the pulp becomes inflamed, pressure begins to build up

in the pulp cavity, exerting pressure on the nerve of the tooth

and the surrounding tissues. Pressure from inflammation can

cause mild to extreme pain, depending upon the severity of

the inflammation and the body's response. Unlike other parts

of the body where pressure can dissipate through the

surrounding soft tissues, the pulp cavity is very different. It is

surrounded by dentin, a hard tissue that does not allow for

pressure dissipation, so increased blood flow, a hallmark of

inflammation, will cause pain.

Causes

When the pulp becomes inflamed, pressure begins to

build up in the pulp cavity, exerting pressure on the nerve

of the tooth and the surrounding tissues. Pressure from

inflammation can cause mild to extreme pain, depending

upon the severity of the inflammation and the body's

response. Unlike other parts of the body where pressure

can dissipate through the surrounding soft tissues, the

pulp cavity is very different. It is surrounded by dentin, a

hard tissue that does not allow for pressure dissipation, so

increased blood flow, a hallmark of inflammation, will

cause pain.

Causes Pulpitis

Pulpitis can often create so much pressure

on the tooth nerve that the individual will

have trouble locating the source of the pain,

confusing it with neighboring teeth, called

referred pain. The pulp cavity inherently

provides the body with an immune system

response challenge, which makes it very

difficult for a bacterial infection to be

eliminated.

Causes Pulpitis

If the teeth are denervated, this can lead to irreversible

pulpitis, depending on the area, rate of infection, and

length of injury. This is why people who have lost their

dental innervation have a reduced healing ability and

increased rate of tooth injury. Thus, as people age, their

gradual loss of innervation leads to pulpitis.

Diagnosis and classification of pulpal diseases

As in all infections, the body answers with increased

circulation (hyperaemia): the supplying blood vessels

expand. Hyperaemia can transform into an acute or

chronic pulpitis. A tooth with acute pulpitis is

extremely sensitive to temperature. Cool air is

sufficient to trigger the pain. In pulpitis acuta

serosa, extended capillary vessels cause the

excretion of granulocytes and serum. Activated

enzymes, causing the breakdown of proteins, create

pus, leading to severe pain in pulpitis acuta

purulenta.

Chronic pulpitis

Chronic pulpitis on the other hand is often

completely without symptoms. It is usually caused

by caries. White blood cells (leucocytes) accumulate

in the pulpa to combat inflammation. The bacteria

cause the blood vessels of the pulpa to become

permeable to serum (pulpitis serosa) and the

number of infection combating cells increases (e.g.,

lymphocytes). Bacteria aggravate the infection. Pus-

forming granulocytes supervene and the pain

intensifies.

Acute pulpitis

In reversible, acute pulpitis, the tooth

reacts to sweetness, cold and heat. The

pain lasts for a short while only. The

sensitivity test is positive. If caries can be

removed without opening the pulpa, the

tooth loses its symptoms. The pulpa can

be kept vital. This acute form of pulpitis is

therefore reversible.

Acute pulpitis

In irreversible pulpitis, which may be acute or

chronic, the tooth is permanently painful. The

dentin is frequently destroyed up to the pulpal

cavity and cariously altered. Pain continues even

after caries removal and medicamentous filling. The

tooth's sensitivity to touch and biting is joined by

decreasing or lacking reaction to a sensitivity test.

The damaged pulpa cannot be reversed to its

original healthy state, it is irreversible.

Diagnosis and classification of pulpal diseases

Vitality loss of the tooth marrow leads to pulpal

necrosis which initially shows no symptoms. This

may occur through a bacterial infection such as

gangrene or after trauma without the participation

of bacteria. If infection occurs in the jaw bone via

the foramen apicale, it results in acute or chronic

apical parodontitis. Diagnosis is confirmed with a

negative sensitivity test. Therapy consists of

trepanation with subsequent root canal preparation

and filling.

Root canal treatment

Root canal treatment can be divided into:

Removal of pulpal tissue

Determination of root canal length

Preparation of root canals

Filling of root canals

Root canal treatment

The determination of the root canal length specifies the

operational length of the root canal instruments by

displaying the length to the foramen apicale. A decisive

factor for the correct filling of the canals is its length,

previously determined by X-ray. The X-ray displays how

far the instrument is away from the root tip and which

length the instruments in the canal may have.

Determination of canal length can also be performed

electrically, whereby a probe is inserted into the canal

and the end of the root canals is indicated by a

measurement device.

Root canal treatment

Root canal preparation serves to prepare the

root canal for root filling. The canals are

extended and planed with flexible, mechanically

or manually driven drills and files, which adjust

even to arched or bent roots. Canal preparation

is also possible with ultrasound.

Canal preparation should be performed up to

the foramen apicale.

Root canal treatment

Root canal treatment

Root canal treatment

Unintended lateral penetration of the root is called

“via falsa” (the “wrong way” in Latin). The objective

of root canal filling is to fill the prepared root canal

with special, bacteria-proof paste and matching

gutta-percha tips and thus ensure sustainable

treatment success. Root canal filling is performed

with endogenous substances, which should be

tissue-compatible, hardening, fluid, dimensionally

stable, parietal, bacteria-proof, non-resorbable and

visible on X-ray.

Root canal treatment

In thermoplastic root canal filling, heated and

formable gutta-percha is injected into the

prepared root canal or inserted as gutta-percha

pins. The insertion of several gutta-percha pins

with hardening pastes is preferred. While the

orthograde root canal filling is normally

positioned from the crown, the retrograde root

canal filling is performed at the tip of the root

(e.g., in root tip resection).

Thank you for attention