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Pulp Therapy in Children

Goals of Pulp TherapyMaintain a healthy tooth for:

Occlusion Arch length/space maintenance Prevention of infection Comfort Mastication Esthetics

Objective of Pulp TherapyThe aim of pulp therapy is to SEAL the tooth off from the external environment

preserve the vital pulp preserve the space for the underlying permanent tooth, eradicate potential for infection.

Clinical Assessment and Diagnosis of Pulp Status

Visual and tactile examination of carious dentin.

History of spontaneous unprovoked pain.

Constant pain.

Pain from percussion.

Pain during the night.

Degree of mobility.

Palpation of surrounding soft tissues.

Radiographic.

Thermal and electric testing unreliable in primary teeth

and permanent teeth with open apices.

Pulp Therapies Available1. Direct pulp cap2. Indirect pulp therapy3. Pulpotomy4. Pulpectomy

5. Apexogenesis6. Apexification

1. DIRECT PULP CAPPINGDirect Pulp Capping is the

placement of a

biocompatible agent

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(calcium hydroxide) on healthy pulp tissue that has been

inadvertently exposed from caries excavation or traumatic

injury.

Treatment Objective: to seal the pulp against bacterial

leakage, encourage the pulp to wall off the exposure site byinitiating a dentin bridge, and maintain the vitality of the

underlying pulp tissue regions.

Indications of Direct Pulp Capping1. Small mechanical exposure ( > 1.0 mm)2. Small traumatic exposure (immediate)3. Asymptomatic vital pulp4. No coronal or periapical pathology

Contraindications for the Direct Pulp Cap

1. carious exposure,2. spontaneous and nocturnal toothaches,

3. excessive tooth mobility,

4. thickening of the periodontal ligament,

5. radiographic evidence of furcal or periradicular degeneration,

6. uncontrollable hemorrhage at the time of exposure, and

7. purulent or serous exudate from the exposure.

Steps in the Procedure

1. Remove caries and make a conventional cavity preparation (which has resulted ina 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

2. INDIRECT PULP CAPPING

Indirect Pulp Capping- the

application of a medicament over a

thin layer of remaining cariousdentin, with no exposure of the pulp.

Can be done in primary and

permanent teeth.

Rationale: There are three dentinal

layers in a carious lesion:

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(1) a necrotic, soft, brown dentin outer layer, teeming with bacteria;

(2) a firmer, discolored dentin layer with fewer bacteria; and

(3) a hard, discolored dentin deep layer with a minimal amount of

bacterial invasion.

Indications of Indirect Pulp Therapy1. Deep carious lesions encroaching upon,but not actually into the pulp2. No history of chronic pain3. No radiographic pathology4. Vital pulp5. Normal tooth mobility6. Normal tooth color

Contraindications for the Indirect Pulp Cap Prolonged spontaneous pain, particularly at night.

Excessive tooth mobility. Parulis in the gingiva approximating the roots of the tooth. Widened periodontal ligament space, interradicular orperiapical radiolucency.

Indirect Pulp TherapySteps in the Procedure

1. Remove infected dentin almost to the point of pulp exposure (some carious dentinmay remain)

2. Place Calcium Hydroxide over the remaining dentin in the floor of the cavitypreparation

3. Place an intermediate restoration (resin modified glass ionomer cement)

4. Observe the tooth closely for 8-12 weeks during formation of secondary dentin5. Remove intermediate restoration, remove residual caries, place final restoration

3. PULPOTOMY

a. Calcium Hydroxide PulpotomyIndications1. 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

b. Formocresol PulpotomyIndications1. Permanent teeth - is not indicated

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