Pulp Therapy in Children

Goals of Pulp Therapy

Maintain a healthy tooth for: Occlusion Arch length/space maintenance Prevention of infection Comfort Mastication Esthetics

Objective of Pulp Therapy

The 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 Available

1. 2. 3. 4. 5. 6. Direct pulp cap Indirect pulp therapy Pulpotomy Pulpectomy Apexogenesis Apexification

1.

DIRECT PULP CAPPING

Direct Pulp Capping is the placement of a biocompatible agent

(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 by initiating a dentin bridge, and maintain the vitality of the underlying pulp tissue regions.

Indications of Direct Pulp Capping

1. 2. 3. 4. Small mechanical exposure ( > 1.0 mm) Small traumatic exposure (immediate) Asymptomatic vital pulp 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 in a pinpoint exposure) 2. Gently clean the preparation with H2O2 3. Evaluate quality of hemorrhage and make sure bleeding stops quickly 4. Place Calcium Hydroxide (Dycal) directly on exposure 5. Place appropriate base and final restoration

2.

INDIRECT PULP CAPPING

Indirect Pulp Capping- the application of a medicament over a thin layer of remaining carious dentin, with no exposure of the pulp. Can be done in primary and permanent teeth. Rationale: There are three dentinal layers in a carious lesion:

(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 Therapy

1. Deep carious lesions encroaching upon, but not actually into the pulp 2. No history of chronic pain 3. No radiographic pathology 4. Vital pulp 5. Normal tooth mobility 6. 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 or periapical radiolucency. Indirect Pulp Therapy
Steps 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 8-12 weeks during formation of secondary dentin 5. Remove intermediate restoration, remove residual caries, place final restoration

3. PULPOTOMY
a. Calcium Hydroxide Pulpotomy
Indications
1. Primary teeth - is not indicated 2. Permanent teeth Carious or traumatic exposure Young vital tooth with incomplete root formation Asymptomatic pulp No periapical or furcation pathology

b. Formocresol Pulpotomy
Indications
1. Permanent teeth - is not indicated

2. Primary teeth Carious or traumatic exposure Young vital tooth Asymptomatic pulp No periapical or furcation pathology

Formocresole Pulpotomy
Steps in the Procedure
1. Remove gross decay 2. Remove roof of pulp chamber 3. Remove coronal pulp tissue 4. Apply dry cotton pellet 5. Apply formocresole impregnated cotton pellets for 1 2 minutes 6. Place IRM and a final restoration

Formocresol Pulpotomy
Criteria for Success 1. Correct diagnosis 2. Isolated field of operation 3. Opening the cavity sufficiently so that the entire pulp chamber is clearly visible 4. Using a medicament of sufficient strength to destroy all forms of bacteria