pulp dental students 07

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 --


2/22

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


3/22

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.


4/22

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


5/22


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


Pathology



(Xray) (Fistu.)

Symptoms


Pathology



(Xray) (Fistu.)

Symptoms




6/22

Deep Caries Into the Pulp Deep caries without Pulpal Exposure


Pathology



(Xray) (Fistu.)

Symptoms




Pathology



(Xray) (Fistu.)

Symptoms




Pathology



(Xray) (Fistu.)

Symptoms



Levels of Pulp Therapyin Primary Teeth

The level of

therapy depends

upon the level ofinjury or disease,

Therefore, careful

diagnosis is vital


7/22

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


8/22

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


Pathology



(Xray) (Fistu.)

Symptoms




9/22

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


Deep Caries,

but No Symptoms

of Pulp Pathology

Evidence of Healing

i.e. Dentin Formation

or Root end Closure


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


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


10/22

2001 - Over 90% success in primary and permanent teeth.


11/22

First permanent molar

with deep caries and

incomplete root

formation

Same tooth

18 months later --

reparative dentin

and complete roots


12/22

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


13/22

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


14/22


15/22

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


16/22

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


17/22

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


18/22


19/22

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


20/22


21/22

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


22/22

pulp dental students 07

Documents