Pulp therapy for primary teeth
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Transcript of Pulp therapy for primary teeth
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1Pulp Therapy forPrimary Teeth
University of MinnesotaDivision of Pediatric Dentistry Definition of Pulp Therapy
Any procedure whereby the pulp of a tooth is treated in an effort to maintain the tooth as a healthy component of the dentition
Over severa l decades , the emphas i s in dentistry has shifted from the concept of a doomed organ that must be removed, to one of organ recovery and health.
Pulp Therapy(Treatment Philosophy)
Advances in pulp therapy have played an important role in this transition
Goals of Pulp Therapy
Maintain a healthy tooth for: Occlusion Arch length/space maintenance Prevention of infection Comfort Mastication Esthetics
Primary vs. Permanent Teeth
Compared to permanent teeth, primary teeth exhibit smaller overall dimension , and:Crowns Less enamel and dentin coverage Relatively larger pulp chambers and pulp horns Narrower occlusal tablesRoots More divergent molar roots Ancillary root canals Resorbable roots
Anatomic Considerations
Average d is tance (mm) f rom the mesial side of pulpchamber to mesial contac t po in t on enamel sur face
First Permanent Second Primary First PrimaryArch Molar Molar Molar
Maxilla 3.0 2.4 2.1Mandible 3.9 2.3 1.8
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2Anatomic Considerations Anatomic Considerations
Objective of Pulp Therapy
The aim of pulp therapy is to SEAL the tooth off
from the external environment
Pulp Therapy
SUCCESS = CORRECT DIAGNOSIS Clinical appearance - hard tissues Clinical appearance - soft tissues Pain - type and when Percussion Pulp testing Radiograph
Clinical Appearance - Hard Tissues
1. Type and amount of caries Gross breakdown Arrested decay
2. Color of the tooth
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3Clinical Appearance - Soft Tissues
1. Inflammation2. Fistula
acute chronic
3. Cellulitis
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4Pain - Type and When
P a i n Histologic S t a t u s
History of Pain Severe pulpitis and necrosisKind
Intensity No correlation with extent of cariesIntensity+duration Severe pulpitis and necrosis
Spontaneous Correlates highly with extent of cariesPain of Percussion Correlates highly with necrosisThermal Sensitivity
Transient Considered normalPersistent Indicates pulpitis and partial necrosisNo response Indicates necrosis
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5Percussion - May Reveal
1. Periapical pathology2. Traumatic occlusion
Pulp Testing
1. Percussion (reliable in children)2. Thermal (reliable in children)
Hot Cold
3. Electrical (not reliable in children)
Radiographs
The single most important diagnostic aid in children is a radiograph
1. Bitewing - will show Surfaces involved Depth of the lesion in relation to pulp
2. Periapical - will show Furcation or apical involvement Presence of calcified tissues External root or bone resorbtion Internal resorbtion
Radiographs
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6Pulp Therapies Available
1. Indirect pulp cap2. Direct pulp cap3. Pulpotomy4. Pulpectomy5. Apexogenesis6. Apexification
Indirect Pulp Capping
Indirect Pulp Capping - Indications
1. Deep carious lesions encroaching upon, but not actually into the pulp
2. No history of chronic pain3. No radiographic pathology4. Vital pulp5. Normal tooth mobility6. Normal tooth color
The intent of Indirect Pulp Capping is to stimulate a tooth to participate in its own recovery
Indirect Pulp CappingSteps in the Procedure
1. Remove infected dentin almost to the point of pulp exposure (some carious dentin may remain)
2. Place Calcium Hydroxide over the remaining dentin in the floor of the cavity preparation
3. Place an intermediate restoration (resin modified glass ionomer cement)
4. Observe the tooth closely for 6-8 weeks during formation of secondary dentin
5. Remove intermediate restoration, remove residual caries, place final restoration
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8To Re-enter or Not Re-enter?
Controversial Will the caries advance if the margins of
the restoration remain sealed? Will removal of the intermediate
restoration further insult the pulp? If the tooth is asymptomatic, will periodic
clinical and radiographic evaluation be sufficient?
Intermission
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9Direct Pulp Capping
Direct Pulp Capping - Indications
1. Small mechanical exposure ( > 1.0 mm)2. Small traumatic exposure (immediate)3. Asymptomatic vital pulp4. No coronal or periapical pathology
Direct Pulp Capping(An Historical Note)
F. A. Hunter (1883) went so far as to present the following formula for pulp capping:
Furthermore, he claimed 98% success and was loudly applauded at the meeting of the Missouri Dental Association in 1883.
Rx:Sorghum Molasses - one pintDroppings of the English sparrow - one pound
Dir: Mix wellSig: For pulp capping
Direct Pulp CappingSteps in the Procedure
1. Remove caries and make a conventional cavity preparation (which has resulted in a pinpoint exposure)
2. Gently clean the preparation with H2O23. Evaluate quality of hemorrhage and make sure bleeding
stops quickly4. Place Calcium Hydroxide (Dycal) directly on exposure5. Place appropriate base and final restoration
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Pulpotomy
Calcium Hydroxide Pulpotomy Indications
1. Primary teeth - is not indicated2. Permanent teeth
Carious or traumatic exposure Young vital tooth with incomplete root
formation Asymptomatic pulp No periapical or furcation pathology
Formocresol PulpotomyIndications
1. Permanent teeth - is not indicated2. Primary teeth
Carious or traumatic exposure Young vital tooth Asymptomatic pulp No periapical or furcation pathology
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1. Correct diagnosis2. Isolated field of operation3. Opening the cavity sufficiently so that the entire
pulp chamber is clearly visible4. Using a medicament of sufficient strength to
destroy all forms of bacteria
Formocresol PulpotomyCriteria for Success
1. Remove gross decay2. Remove roof of pulp chamber3. Remove coronal pulp tissue4. Apply dry cotton pellet5. Apply formocresole impregnated cotton pellets for 1 - 2
minutes6. Place IRM and a final restoration
Formocresole PulpotomySteps in the Procedure
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Pulpotomy - Success Rates(Summary from several studies)
Ca(OH)2 FormocresolHistologic 50% 92%Radiographic 64% 93%Clinical 71% 97%
Formocresol is the standard from which other medicaments are rated.
Thank You
University of MinnesotaDivision of Pediatric DentistryUniversity of Minnesota
Division of Pediatric Dentistry