4 - 10) pulp therapy for the young permanent dentition

7/22/2019 4 - 10) Pulp Therapy for the Young Permanent Dentition

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Pulp therapy for the young permanent dentition

The dr said that we have a full lecture in endodontics talking aboutpulp therapy for permanent dentition, but in the lecture we will talkabout pulp therapy for young permanent teeth which meanpermanent teeth in children especially the 6s and the 7s teeth, But inthe adult its different.

For example : in child or adolescent , if we do PRR and we reach thedentine we have to place a liner in the cavity but in the adult we haveto estimate that the cavity is deep so its subjective decision nobodycan say if we reach 3 or 5 or 6 mm we have to place a liner.

The types of pulp therapy techniques that we apply for these youngpermanent teeth differ from those for adult permanent teeth by thistechnique less invasive than the adult so we can go through thesetechnique in the beginning for adult tooth .

So the pulp in permanent teeth is necessary for dentine formationand loss of vitality in these young teeth before root completion leavesthin, weak root prone to fracture.

The thing we should know that the dentine in these teeth still thinhowever its erupted, so the dentine has not reach the full thickness,why this dentine is important ? Because this dentine will give thetooth its strength and prevent caries from reaching the pulp.

Classification of pulp therapy for young permanent teeth :

1.Apexogenesis: vital pulp therapy procedures.

2.Apexification: non-vital pulp therapy procedures used with RCT

which we used for necrotic pulp tissue teeth.

In modern dentistry this classification could be not enough becausenowadays we can do apexfication in RCT by the MTA material whichclose the apex of then we fill it with GP and finish the treatment in 1

visit.


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Again:

Apexogenesis: vital pulp therapy procedures performed toencourage physiological development and formation of the root apexso by the prevention of the dentine the root apex will continue

formation by stimulation of the odontoblast.

The Aim: to promote root development and apical closure.

Goals of apexogenesis :

1.Sustaining of viable HERS (Hertwings epithelial root sheet ) andthis HERS is responsible for root formation which is important incrown/ root ratio (C-R ratio ), imagine that the tooth with normalcrown length and abnormal root length this will affect the stability ofthe tooth so it will affect the occlusion which may result in occlusiontrauma .

2.Maintaining pulp vitality, allowing odontoblast to lay down dentinewhich makes the root thicker and less chance of fracture.

3. promoting root end closure to fill the canal with GP .

4.Generating a dentine bridge at site of pulpotomy.

The techniques:

1-indirect pulp cap: its the same procedure we apply for theprimary teeth and used when :

- we have a deep caries and start excavation from the walls andthen the walls until we reach the floor so we will end up withpulp exposure of immature root apex .

- trauma class II fracture and immature apex, this year. thwewill discuss in 5

- Asymptomatic tooth: means there is no symptoms ofirreversible pulpitis or necrotic pulp but its normal to havereversible pulpitis symptoms.

- No abnormal radiographic change changes so we still need RGat the beginning.


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What we mean by changes?

We dont need periodontal space widening or per apical radiolucent

area or bone and root resorption.. etc.

Now the indirect pulp cap procedures:

infected dentine should be removed

the affected dentine will remineralise and the odontoblasts will formreparative dentine by the applying material thus avoiding the pulpexposure.

Later they make it by step-wise excavation, they remove as much theycan and leave a single layer ,then placing calcium hydroxide andfilling and get the patient to come back after 3 month to open thetooth again hoping that we have a reparative dentine then remove thesingle layer that we left because now we have a dentine bridgeformed.

Tooth maybe re-entered following procedure to remove remainingcaries,

So clinician differ on whether this should single visit or 2 visits (openit).the dr prefer 1 visit with good coronal seal ( meaning put a crownimmediately).

IPC Rationale: the tooth that has carious lesion nearpulp,biocompatible material placed over layer of remaining cariousdentine to prevent pulp exposure and stimulate pulp tissue healingrepair.


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Indications:

- normal pulp

- reversible pulpitis (clinical &RG criteria)

Material that we use in IPC:

1. Calcium hydroxide (always the material that has been used)2. ZOE (acceptable,becuse it has a problem which is the coronal

seal but you can place a layer of it and then cover it with GI)3. GIC (excellent because it an adhesive material)4. RMGI (the dr`s choice,also an adhesive material and it has a

properties of composite and GIC)5. The final restoration which is the SSC in posterior and AECR in

anterior teeth

The Succes rate : 74% to 99% of cases (depended on the coronalseal)

IPC Objectives:

1. Restorative material seal dentin from oral environment2.Vitality of tooth should be preserved3. No pos treatment signs/symptoms (pain,sensitivity)4. No RG evidence of external or internal RR or pathologic

changes5. Teeth with immature root apex&continuos root development

2. Direct pulp capping

Direct pulp capping : is the application of medicament or dressing to

the exposed pulp in an attempt to preserve the vitality.

when small exposure of the pulp is encountered during cavity

preparation, and the hemorrhage starts so we need first to stop the

bleeding then we quickly cap the pulp tissue either by Calcium

Hydroxideor MTA, and then place the restoration that seal the


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tooth, usually we place GIC then composite on top or a crown on

posterior teeth.

IMP. NOTE:we never place our Calcium Hydroxide unless

we are sure that you stopped the hemorrhage, if there is any

hemorrhage and you put the Calcium Hydroxide you will

not get a good results, its like you are starting a fire inside

the pulp, you are inducing the undifferentiated

mesenchymal cells to form odontocalsts and start resorbing

the pulp and cause internal root resorbtion, so its very

important to arrest the bleeding.

Indications:

There should be minimal exposure to the pulp like :

1- mechanical exposure of the pulp

2- traumatic exposure of the pulp

in all cases the pulp should be normal.

Materials:

1. Now the first material that we used in such case is CalciumHydroxide, am not going to explain in details about it because

you should know it by heart.2. is MTA ( Mineral Trioxide Aggregate ).(shaggob w 3allosh ento

3arfeen 3anno:P)

When they made histological evaluation to MTA they found that it

causes less inflammation, and induce the formation of dentin bridge,

the MTA is a material similar to concrete ( ), its formed of

many minerals & salts like aluminum, iron oxide, carbon, it was


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developed by a Turkish dentist called Mahmoud Tarabenjad.(kan

ymathel m3 lamees w ya7ya:D)

as we said MTA is similar to concrete, for that its so hard to drill

through it thats why they use it in pulp capping, preparation, and

many uses nowadays.

MTA use to be grayish in color just like amalgam, and now they have

developed other versions that are whiter in color, because when we

want to use it in coronal pulp therapy, we don't want the crown to

stained and look grayish so they develop white MTA.

3. Dentin bonding agent has been used in some studies to cap thepulp.

Now why Calcium Hydroxide is the most successful direct

pulp capping agent and how &why does it work?

1. high PH2. anti-microbial properties.

the dr now explaining a pic :

This is the technique for direct pulp capping, we have an exposed

pulp, so the first layer here you place is Calcium Hydroxide or MTA,

then you add another layer of GIC to cover all dentin, finally the rest

of the tooth filled up with composite for anterior teeth, and stainless

steel crown for posterior teeth.

I wrote to you in the slides to put composite 4-6 hours later in case

you used MTA,

why ?

-because MTA needs about 4 hours of setting time.


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If you use MTAyou must have a moist environment, usually we

use a wet cotton pellet then we cover it with temporary filling, and

then we go back, remove the cotton pullet, and continue our

composite filling.

The success rate:

15 % up to 10 yearsstudy done by students

82 % up to 21 monthsstudy done by clinician

The objectives

they are the same for IPC:

1. pulpal vitality

2. no pathological signs

3. continuation of root formation

Pulpotomy

its the same procedure for primary & permanent teeth except in the

level which we cut the pulp, in the primary we cut up to the cervical

level we remove all the coronal pulp, in permanent teeth we have two

types of pulp therapy :

1. partial pulpotomy (cvek pulpotomy) : we remove only 2 mm of the

coronal pulp and we place our medicaments (CH,MTA)

2. cervical pulpotomy : we remove all the coronal pulp like the

primary teeth


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In both types of permanent pulpotomy we either use Calcium

Hydroxide or MTA

The difference between primary & permanent teeth pulpotomy :

1- the level of amputation

2- the material (CH,MTA)

indications of pulpotomy:

when pulp is exposed: infected & affected coronal pulp amputatedand remaining radicular tissue judged to be vital by CLINICAL and

Radiographic criteria.

so the partial pulpotomoy or CVEK pulpotomy (another name) :theaseptic (using rubber dam),surgical removal pf exposed pulp anddentine surrounding the exposure to a depth of 1.5-2mm..

CVEK indications:

1. traumatic or carious (


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PULPOTOMY,you irrigate again and you apply a wet cottonpellet (with NS),apply some pressure and you wait for thebleeding to stop then you apply your medicaments..the medicaments is the same for both partial and cervical pulpotomy--> CALCIUM HYDROXIDE

the pulp wound covered with paste of CH against non bleedingpulp,(essential as blod clot will diminsh chances for hard barrierformationj&long term success)..

CVEK MATERIALS:

1.they apply a layer of non-setting CH and then a layer of Hard settingCH then they apply the RMGI or GIC and then the permanentrestoration..2. the other option is to use MTA the the RMGI or GIC then the

permanent restoration..

The dr. then talked about pictures in slides,pls go back and check

them.

Cvek pulpotomy objectives:

Your objectives are the same objectives as any vital pulp therapy

technique.

success rates: are 96% on traumatically exposed teeth , as u see the

first study in 1978,the second one in 1983 and the third one in 1993 in

which the success rate is 94% which is quite high ,this is on the

carious permanent molars.

Factors affecting the success rates :

1.avoid incorporating dentin chips into the pulp wound , meaning

when you are removing the caries make sure that all the cariesremoved before you enter the pulp , with irrigation clean the cavity

well before entering the pulp because any dentin chips infected with

microorganism enter the pulp will lower the success rate.

2.marginal seal.(very imp)


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Cervical pulpotomy :

- procedure is as described for formacresol pulpotomy , but weuse calcium hydroxide ad medicaments

- re-entry following completion of root formation is controversial- and some people recommend RCT later , those are endodontists

who said that after cervical pulpotomy you should do RCT.

So this is cervical pulpotomy with the same technique :

1. we put the calcium or MTA2. then we put glass ionomer3. then all sealed with composite.

the possibility of pulp necrosis, infection and pulp canal obliteration

prevent negotiation of pulp canal later,and this is the reason why

endodontists recommend RCT because these canals may start to

close.

calcification is infrequent if the pulpotomy procedure is meticulous ,

this is of course opinions of Cvek and he said that there is no need forRCT if the work done in right manner because there is no calcification

will happen.

Objectives is the same again!!

Apexification:

Its a method of inducing calcified barrier in root with open apex

which is necrotic.

Now , apexification is like RCT except if you have an open apex due to

immaturity , which mean there is viable tissue at the apex that has

the willing to finish the root formation if it given a chance by

removing just the necrotic tissue , this necrotic tissue make the ability

of the cells to complete root formation difficult.


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So if you remove the necrotic tissue and repeal the inflammation and

give these cells a booth by filling with calcium hydroxide, and calcium

hydroxide will provide the proper environment for these cells to work

by inducing enzymes and providing alkanality and bacteriostatic

activity.

Also the odontoblasts will start their work so there will be induction

from both sides so the root formation will complete and odontoblasts

will layer dentin in the root and we will have at the end the root apex

formation.

Goals of apexification

1.Stimulate and preserve formative activity of granulation tissue cells

in apical part of root canal which enhances the formation of calcified

callus at apical opening.

2.to form hard tissue barrier to prevent over extension of root filling

material into the periapical tisses.

Objectives of apexification

1.induce root end closure.

2.no post treatment signs and symptoms.

3.no radiographic evidence pathology.

Indications of apexification

Indicated for non vital permanent teeth with incompletely formed

roots.

Techniques of apexification

There are two techniques :

1. conventional technique which is multiple visits,2. modern technique which occur in one to two visits.


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The old technique (conventional) still applicable and requires in

the first visit preoperative periapical radiographs ,local anesthesia ,

rubber dam ,determining working length , cleaning and shaping,

irrigation with sodium hypochlorite , non setting calcium

hydroxide and IRM/GIC.

The next visit after 3 months we check if the calcium hydroxide still

there or washed away,if its washed away then again,we do cleaning

and shaping,irrigation and we put a new layer of non setting calcium

hydroxide until the root closes.

This technique will take about 6 months to one year or even 1.5 year

depending on which stage of root formation we start the procedure,if

the formation is completed then it will take 6 months but if it in themiddle of formation then it will take 1 year.

Its very necessary for calcium hydroxide to go all the way to the end

of root because this is where you want apical closure to occur,if it

placed in the middle then the there will be barrier in the middle and

we wont be able to reach the apical part of root.this is why after

application of calcium hydroxide you should take a radiograph to

verify how far the application was.

The new technique (modern) requires in the first visit preoperative

periapical radiographs ,local anesthesia , rubber dam,access

,determining working length , cleaning and shaping, irrigation with

sodium hypochlorite.here we put non setting calcium hydroxide in

one visit because the canal is infected and calcium hydroxide will

work and just clean it, then we get the patient after one week to put

MTA.here we will be finished and get the apical closure and after 4

hours of MTA application we can get the patient back or after one

week just to complete the filling.

So the second visit can be the last one to put gutta percha .


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Apical closure

Various types of apical closure have been reported its how to verify

if there is apical closure and it is the time to put the gutta percha, this

is in case of old technique with calcium hydroxide,it appears that

these types of apical closure simply relate to the level to which the

filling material was placed within or beyond the apical foramen.

The calcified bridge formed following apexification is a porous

structure .meaning its quality is not as the original dentin ,but its a

little bit lower.

If it difficult to determine if and when apical closure has been

achieved then there is two ways to know that:

1.by radiographs.

2.by feeling it with a paper point.

Types of apical closure

1.apical closure with definite ,minimal ,recession of root canal.

(obliterated apex)

2.the obliterated apex develops without changes in root canal space.

3.thin , calcific bridge has developed but without radiographic

evidence.

4.calcific bridge but can be determined radiographically .

Materials of apexification

1.calcium hydroxide.

2.MTA which produces hard tissue,now why MTA become morewidely acceptable nowadays? Because it reduces the treatment

time.in other words the one-visit shorten Tx time.

potential for fractures of immature teeth with thin roots

reduced.because they found that with multiple application of non


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setting calcium hydroxide over 1 or 1.5 year will increase the risk of

root fracture because the dentin is thin. So the quicker you fill the

canal with MTA and gutta percha you will get a stronger root and you

will protect the tooth.for this reason MTA is more preferable.

Treatment time:

Apexification requires 1 year +/- 7 months, and the older children

with narrow apex require less than younger children.also the teeth

without periapical infection require less than those with infection.

The dr skipped the RCT techniques because we know about it..

Done By Musap AL-rawi..

Moori,3o3o,shaggob,ziko,roro

4 - 10) pulp therapy for the young permanent dentition

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