Documente Academic
Documente Profesional
Documente Cultură
PRIMARY TEETH
Dr Feda Zawaideh
BDS, ADC(Vic), GradDipClinDent, DClinDent(Melb), FRACDS,
FRACDS (Paed), JDB
PULP BIOLOGY
Pulp-dentine complex
Primary dentinogenesis
Secondary dentinogenesis
Tertiary dentinogenesis
Reactionary dentine
Reparative dentine
Tziafas, Smith, Lesot. Designing new treatment strategies in vital pulp therapy.
Journal of Dentistry 2000; 28: 77-92.
Tziafas, Smith, Lesot. Designing new treatment strategies in vital pulp therapy.
Journal of Dentistry 2000; 28: 77-92.
PULP THERAPY
The goal of pulp therapy in the primary
& mixed dentitions are:
INDICATIONS &
CONTRAINDICATIONS OF
PULP THERAPY
Factors influencing the decision to retain
primary teeth:
Medical history
Behaviour factors
Dental factors
MEDICAL HISTORY
CONTRAINDICATIONS:
Immunosuppressed patients
MEDICAL HISTORY
INDICATIONS:
Oligodontia as in Ectodermal
Dysplasia
BEHAVIOUR FACTORS
CONTRAINDICATIONS:
Uncooperative or non-compliant
patient/parent
INDICATIONS:
Cooperative child
DENTAL FACTORS
CONTRAINDICATIONS:
Unrestorable tooth
DENTAL FACTORS
INDICATIONS:
Well-maintained arch with intact
primary dentition
Orthodontic considerations and space
maintenance
Lack of a permanent successor
Minimal root resorption and no
mobility
CASE ASSESSMENT
CASE ASSESSMENT
Medical history
Dental history and attitude to
treatment
Clinical examination
Special tests
- Pulp sensitivity tests
- Mobility and tenderness on
percussion
- Radiographic examination
- Direct visual examination of the pulp
chamber
PULPAL DIAGNOSIS
Healthy
Reversible pulpitis
Irreversible pulpitis
Total pulp necrosis
Differentiation between reversible and
irreversible pulpitis is extremely
difficult
INDIRECT PULP
TREATMENT
The procedures or steps taken to
protect or maintain the vitality of
the carious tooth that, if
completely excavated, the decay
would result in a pulp exposure
Al-Zayer M. Pediatric Dentistry, 25(1): 29-36, 2003
INDIRECT PULP
TREATMENT
INDIRECT PULP
TREATMENT
INDIRECT PULP
TREATMENT
All caries at the DEJ must be removed
Remove the infected dentine
(superficial layer) This layer contains the majority of
microorganisms and their toxic products that are also the source of
continuous insult to the pulp. The infected layer must be removed
to allow the healing of the dental pulp.
Apply liner/base
Restore the tooth
Clinical Technique
INDIRECT PULP
TREATMENT
INDIRECT PULP
TREATMENT
Re-entry into the cavity has been
questioned especially if a durable
restoration is placed initially and no
adverse symptoms develop
An excellent coronal seal is required to
ensure good success rate with this
technique
Stepwise excavation technique-reentry in 2-3 weeks (unjustified)
Stepwise Excavation
Diagrams demonstrating the
less invasive stepwise excavation
procedure. A closed lesion
environment before and after
first excavation (a, b) followed
by a calcium hydroxide
containing base material and a
provisional restoration. During
the treatment interval the
retained demineralized dentin
has clinically changed into signs
of slow lesion progress,
evidenced by a darker
demineralized dentin (c, d).
After final excavation (e) the
permanent restoration is made
(f ). Red zones indicate plaque.
Bjorndal L. Indirect pulp therapy and stepwise excavation. Pediatric Dentistry 2008;
30:225-9.
Prognosis
INDIRECT PULP
TREATMENT
Success rates improved when:
A base is used over the liner
A SSC is used to restore the tooth
Treatment performed on second
primary molar than a first primary
molar
Al-Zayer M. Pediatric Dentistry, 25(1): 29-36, 2003
INDIRECT PULP
TREATMENT
Radiographic evaluation of a mandibular first and second primary molar that received indirect pulp
treatment with adhesive resin only and were considered successful outcomes after 2 years. Preoperative
radiograph (a), immediate postoperative (b), and 6 months (c), 12 months (d), 18 months (e) and 24
months (f) after indirect pulp treatment.
Radiographic evaluation of a mandibular first primary molar that received indirect pulp treatment with adhesive
resin only and was considered a failure after 18 months. Preoperative radiograph (a), immediate postoperative (b),
and 6 months (c), 12 months (d) and 18 months (e) after indirect pulp treatment. The interradicular lesion
accompanied by external and internal root resorption observed in panel (e) was indicative of treatment failure.
Radiographic evaluation of a mandibular second primary molar that received indirect pulp treatment with
calcium hydroxide and was considered a successful outcome after 2 years. Preoperative radiograph (a),
immediate postoperative (b) and 6 months (c), 12 months (d), 18 months (e) and 24 months (f) after IPT
Radiographic evaluation of a mandibular second primary molar that received indirect pulp treatment with calcium
hydroxide and was
considered a failure after 18 months. Preoperative radiograph (a), immediate postoperative (b) and 6 months (c), 12
months (d) and 18 months (e)
after indirect pulp treatment. The interradicular lesion accompanied by external root resorption observed in panel (e)
was indicative of treatment failure.
PULPOTOMY
Involves the amputation of the coronal
portion of the affected or infected dental
pulp. Treatment of the remaining vital
radicular pulp tissue surface should
preserve the vitality and function of all or
part of the remaining radicular portion of
the pulp. The coronal pulp chamber is filled
with a suitable base and the tooth restored
The American Academy of Pediatric Dentistry Reference
Manual
PULPOTOMY
Indications:
Large carious lesion involving more
than 1/3 of marginal ridge in a
restorable tooth
Vital tooth free of radicular pulpitis
with pain of short duration, no
swelling, mobility, tenderness or pus
discharge, no periapical pathosis or
inter-radicular bone loss
At least 2/3 of root remaining
PULPOTOMY
Clinical contraindications:
Unrestorable tooth
History of spontaneous/persistent pain
Irreversible pulpitis or pulp necrosis
Pus discharge
Pathological mobility
Swelling of pulpal origin
Sinus tract or fistula
Hyperaemic pulp
PULPOTOMY
Radiographic contraindications:
External or internal root resorption
Periapical or furcal pathology
Radicular bone loss
Pulp calcification
Less than 2/3 root left
Permanent tooth close to eruption
PULPOTOMY MATERIALS
1.
2.
3.
PULPOTOMY-MATERIALS
Formocresol
Ferric sulphate
Gluteraldehyde
CH cement
Ledermix Cement
Sodium Hypochlorite
Electrosurgery
Laser therapy
Mineral Trioxide Aggregate (MTA)
Bone morphogenic proteins (BMPs)
FORMOCRESOL
PULPOTOMY
Buckleys Formocresol
Tricresol-35%
Formaldehyde-19%
glycerol-15%
water-31%
1:5 dilution
The pulp remains half dead, half vital, and
chronically inflamed.
Success rate ranges from 70-97% but
diminishes with time.
FORMOCRESOL
PULPOTOMY
Fixation of the pulp
tissue by direct contact
Bactericidal
3 layers form: fixation,
coagulation necrosis,
vital tissue
Concern regarding
systemic toxicity,
carcinogenicity and
mutagenicity
Success rate:70-100%
FERRIC SULPHATE
PULPOTOMY
GLUTERALDEHYDE
PULPOTOMY
Rapid fixation of the pulp tissues
Less penetration into the periapical
tissues
Toxicity concerns
Eye irritation and allergic reaction
Short shelf life
Higher success rates than Formocresol
CALCIUM HYDROXIDE
PULPOTOMY
Antibacterial activity
Surface layer of coagulation necrosis
Associated with high rates of internal
resorption
Success rate of 60%
Recently questioning low success rate
attributing that to incorrect diagnosis
and contact with the blood clot
MTA
Mineral trioxide aggregate (MTA):
It has excellent sealing ability, biocompatibe, induces hard
tissue formation, has antimicrobial properties, maintains pulp
integrity & promotes healing without cytotoxic effect, It has
higher long term clinical and radiographic success rate than
pulp dressing materials like FC.
MTA is a powder composed of a mixture of a refined Portland
cement and bismuth oxide, reported to contain trace amounts
of SiO2, CaO, MgO, K2SO4, and Na2SO4.
MTA powder is mixed with sterile water in a 3:1 powder/liquid
upon hydration, a colloidal gel is formed that solidifies to a
hard structure in approximately 34h, with moisture from the
surrounding tissues assisting the setting reaction.
Evidence on MTA
MTA vs FC:
MTA-treated teeth showed no clinical or radiographic
pathology whereas internal resorption was detected in the FC
group after follow up periods ranging from 6-30 months .
The success rate of pulpotomy was 97% for MTA and 83%
for FC after a follow up period of 74months , internal
resorption occurred more in FC pulpotomy. (Holan 2005)
MTA was superior to FC in pulpotomy and might be FCs
suitable replacement resulting in a lower failure rate & lower
undesirable responses. (Peng 2006)
ND:YAG vs FC pulpotomy
PULPOTOMY-PROGNOSIS
Regardless of the
material used
success depends on
pulp status
Reasons for failure:
- Incorrect diagnosis
- Inadequate coronal
seal
PULPECTOMY
Involves gaining access to the root
canals which are then debrided,
enlarged and disinfected. The canals
are filled with a resorbable material
The American Academy of Pediatric Dentistry Reference Manual
PULPECTOMY
Indications:
Tooth with irreversible pulpitis or
necrotic pulp tissue
Non-vital tooth with prolonged history
of pain, swelling, mobility,
radiolucency involving the furcation
area
Persistent bleeding during a
pulpotomy
PULPECTOMY
Contraindications:
Periradicular involvement extending
to the permanent tooth bud
Pathological resorption of > 1/3 root
Excessive internal root resorption
Perforation of the floor of the pulp
chamber
In 1992, Salama et al
attempted to determine the
length of the root canals of
primary maxillary incisors
and mandibular molars
SINGLE STAGE
PULPECTOMY
TWO-STAGE PULPECTOMY
Presence of an acute abscess
Persistence of discharge
Patient is in pain
2 stage pulpectomy with Formocresol
intermediate dressing and antibiotics
Pure ZOE.
A mixture of ZOE with formocresol and glycerine.
Iodoform paste.
Kri paste; a mixture of iodoform, camphor, parachlorophenol &
menthol.
The Overall success rate for KRI paste was 84% versus 65% for
ZOE, Overfilling with ZOE led to a failure rate of 59% as
opposed to 21% for KRI, Conversely, underfilling led to similar
results, with a failure rate of 17%f or ZOE and 14% for KRI.
(Holan & Fuks 1993)
Vitapex, a commercial
product containing a viscous
mix of calcium hydroxide
and iodoform in a syringe
with disposable tips. The
main ingredients are
iodoform, calcium
hydroxide, and silicone.
PROBLEMS IN PULP
THERAPY
Pain/poor patient cooperation
Acute infection
Persistent draining sinus
RESTORATIONS
Ideally SSC
Amalgam
Resin-modified GIC
Composite resin
SEQUELAE OF PULP
THERAPY
Effect on eruption time of permanent
successor
Enamel defects on permanent
successor possible related to the preexciting infection
Indications
Extensive caries
Pulpotomy/pulpectomy
Malformed teeth
Hypoplasia
Hereditary Conditions (AI, DI)
Fractured teeth
Severe attrition of primary teeth
Mesial lesions on first primary molars
Contraindications
Esthetics
Teeth that are nearing exfoliation
Mechanical problems
space loss
caries beneath the level of the bone
Permanent restoration in the permanent
dentition
77% nickel
15% chromium
7% iron
plier
Contouring plier
Polishing
Step By Step
Caries Removal
Complete pulp therapy if necessary
Proceed with crown preparation
Overview
Occlusal reduction
Proximal reduction
Buccal and Lingual
reduction
Beveling
Round all sharp line
angles and corners
Occlusal Reduction
1.0 1.5 mm
Proximal Reduction
Proximal Slices
Angulation of Slices
Ledging
Buccal-Lingual Reduction
Beveling
Crown Adaptation
Gingival Contours
Buccal gingival contour of second primary molar-smile
Guidelines
Check for
high spots on occlusal surface
ledges
Check for
crown too wide (preliminary contouring)
crown too long
tissue caught in margin
Cementation
Post-op instructions ?
Clinical Variations
Back-to-back chrome
crowns
Second primary molars
Complications
Any Questions???