Pediatric Dentistry I Forth Year

2. Clinical Assessment
 Extent of lesion
 location, color
Mobility
 R/O root resorption
 Soft tissue swelling
 Lymphadenopathy
Sensitivity to
percussion
reliable in primary
teeth
 Pulp exposure
hemorrhagic v
necrotic
 Pulp testing
Electrical
 thermal

3. Assessment of Pain
Types of Pain Pulp Status
Spontaneous
Nocturnal Irreversible: Non-vital treatment
Constant
• Thermal
• Chemical Reversible: Vital treatment
• Intermittent
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5. Reliability of Pulp Testing
Teeth Primary Young p Mature p
Electrical --- + +
Thermal + + ++
Percussion ++ + +
• No single diagnostic test is reliable

11. RADIOGRAPHIC
ASSESSMENT
• Proximity of caries
• Assess the periodontal ligament
• Furcational pathology. This is due to the
accessory canals and foramina present on the pulp
chamber floor of primary molars.
• Internal and external root resorption
Differentiate between root pathology and normal
physiologic root resorption.
Always check the antemere on a radiograph.

12. Radiographic Criteria for
Health Pulp
• Adequate periodontal support
• No decalcified lesions or root fractures
• No internal/external resorption or
• Radiolucency
• Integrity of lamina dura

13. RADIOGRAPHIC
ASSESSMENT

14. Moss et al. 1965:
• accessory canals in furcation area
• no vital pulp tissue with interradicular bone loss
• increased porosity of pulpal floor when infected
Wrbas et al. 1997:
• 77.5% of mandibular primary molars had
accessory canals in floor of chamber

17. Histologic Components of
Primary Pulp
 Lymph vessels
 Blood vessels
 Nerve tissue
 Collagenous fibers
 Fibroblasts
Histologically similar to young permanent
pulp
 Defense cells
macrophages, neutrophils
 Lymphocytes
 Odontoblasts
 Odonto-/osteoclasts

18. Pulp response in primary molars with
large proximal caries?
• Does occlusal caries induce similar pulp
response to proximal caries?
• Pulp response in primary molars with large
proximal caries?

20. Indirect Pulp Capping
• Indications
– Deep carious lesion
– Incomplete caries removal
– No pulp exposure
• Objectives (AAPD)
– Complete seal, preserve vitality, no post-tx
signs/symptoms, formation of tertiary
dentin,
– No evidence of pathology/resorption

21. Pulp Capping Agents
• Ca(OH)2 still widely used
• ZOE - chronic inflammation
• Mineral trioxide aggregate (MTA)

22. Technique of indirect pulp cap
• LA & RD application.
• Caries removal without pulp exposure.
• CaOH application seal the cavity
• Evaluation after 6-8 weeks
– Maintenance of pulp vitality
– Normal radiograph
• Permanent restoration

23. Direct Pulp Cap
• Indications
– small mechanical or traumatic exposure in primary or
permanent tooth
• Contraindicated for (carious) exposure in primary
teeth
– persistent inflammation
– internal resorption - related to high cellularity
– calcific metamorphosis
• Pulpal inflammation occurs before exposure.
• Pulpal inflammation quickly becomes irreversible

24. Direct Pulp Cap

25. A pulpotomy is defined as the surgical removal of
the entire coronal pulp pre-sumed to be partially or
totally inflamed and quite possibly infected,
leaving intact the vital radicular pulp within the
canals.
The aim is to relieve pain due to pulpalgia and
leave the vital pulp in roots for its completion , if
incomplete (apexogenesis )
DEFINITION

26. Pulpotomy for Primary Teeth
• Indications (AAPD)
–infected coronal tissue can be amputated
–remaining radicular tissue vital (clinically and
radiographically)
• Objectives (AAPD)
–preserve vitality of radicular pulp
–no adverse signs or symptoms
–no harm to succedaneous teeth

27. Pulpotomy: Clinical Indications
• Mechanical or carious exposure
• Inflammation limited to coronal pulp
• Absence of spontaneous pain (?)
• Absence of swelling or alveolar abscess
formation
• Restorable tooth

28. Pulpotomy Contraindications
• History of unprovoked pain (?)
• Presence of fistula or swelling
• Evidence of necrotic pulp
• Uncontrolled pulpal hemorrhage
• Periapical or bifurcation radiolucency
• Pathologic resorption
• Dystrophic calcification
• More than 1/3 root resorption

29. contraindication

30. The ideal dressing material /
medicaments for radicular pulp
• Non-toxic, non-mutagenic &non-carcinogenic.
• Biocompatible.
• Dimensionally stable.
• Bactericidal.
• Harmless to pulp & surrounding structures.
• Promote healing of the radicular pulp.
• Not interfere with physiologic process of root
resorption.

31. classification
Pulpotomy
Partial pulpotomy complete pulpotomy
calcium hydroxide formocresol
pulpotomy pulpotomy

32. CLASSIFICATION
Non vital pulpotomy Vital pulpotomy
Beechwood cresol Devitalization
Formocresol Preservation
Regeneration

33. Vital pulpotomy technique
Devitalization
Preservation
1. Glutaraldehyde
2. Ferric sulphate
Regeneration
1. Bone morphogenetic
protein
2. Dentin chips
Single sitting –
Formocresol
Electrosurgery
Laser
Two stage –
Gysi triopaste
Easlick’s formaldehyde
Paraform devitalising pastePreservation

34. Categories of Medicaments
 Fixatives
 FMC, glutaraldehyde
Mineralizing and/or
bacteriostatic agents
 Ca(OH)2, tricalcium
phosphate
Palliative sealers
 ZOE
 Obturators
 mineral trioxide aggregate
 Coagulants
 ferric sulfate, aluminum
chloride
Antibiotics/Antimicrobials
 erythromycin, others
Tissue healing agents
 collagen, BMP
Glucocorticoids
corticosteroids

35. Actions of Formocresol
• Composition (Buckley’s Solution )
• 19% formaldehyde,
• 35% cresol in vehicle of
• 15% glycerin and water
• Fixation with progressive fibrosis
– acidophilic zone: fixation
– pale staining zone: atrophy
– broad zone of inflammatory cells
• Bactericidal - biggest benefit?
• No dentin bridging

38. Formocresol Pulpotomy
Success Rates
• Range of success rates in literature:
• 62-100% depending on study and criteria used
• Clinical>Radiographic>Histological
• Formocresol pulpotomies may be empirical
clinical successes, but histologically they are
failures to one degree or another

39. Effects on Succedaneous
Teeth
• Pruhs et al. (1977)
• Rolling and Poulsen (1978)
• It is possible that enamel defects in premolars
were caused by inflammation prior to the
pulpotomy

40. Concerns About Formocresol
• Systemic Toxicity
• Myers et al 1983
• Damage to Permanent Successor
• Pruhs et al 1977.
• Rolling and Poulson 1978
• Mutagenic
• Ranly 1984

41. Dilution of Formocresol
• 1:5 dilution
– – 1 part FMC, 4 parts vehicle (3 parts glycerin, 1
part distilled water)
• Histology and clinical success comparable to
full strength
• Neither produces ideal histology
• Long-term clinical success of 1:5 still
questioned by some

42. Two-Appointment Pulpotomy.
Indications
1 Evidence of sluggish or profuse bleeding at the amputation
site
2 Difficult-to-control bleeding
3 Slight purulence in the chamber but none at the amputation
site
4 Thickening of the periodontal ligament
5 A history of spontaneous pain without other
contraindications.
Contraindications.
(1) Nonrestorable
(2) Soon To Be Exfoliated
(3) Necrotic.

43. Procedure
1. The steps are the same as for the one-appointment
procedure
2. A cotton pellet moistened with diluted formocresol is
sealed into the chamber for 5 to 7 days with a durable
temporary cement.
3. At the second visit, the temporary filling and cotton
pellet are removed and the chamber is irrigated with
hydrogen peroxide.
4. A ZOE cement base is placed.
5. The tooth is restored with a stainless steel
crown.

44. Partial pulpotomy (pulp
curretage )
It is removal of coronal pulp tissue up to the level of
healthy pulp. This process is also known as partial
pulpotomy.
INDICATIONS : --
when zones of inflammation has extended more
than 2 mm. in an apical direction but has not reached
root pulp.
Eg. A traumatic exposure (a few days post injury
in a large young pulp)

45. TECHNIQUE
1. Area is anaesthetised and isolated
2. A 2 mm. deep cavity is prepared into pulp using
sterile diamond bur and copius water coolent
3. Excess blood is removed by saline & small cotton
pelletes
4. Calcium hydroxide is placed onto cavity
5. Sealed with ZOE reinforced IRM restoration.
IT IS RARELY SUCESSFUL AND
HENCE HAS NO CLINICAL SIGNIFICANT.

46. REASONS FOR FAILURE
Pulp is highly vascular so, even with slightest
infection in any corner of pulp , the whole of it
gets infected very quickly.
Its practically impossible to remove one part
of coronal pulp without disturbing the other
parts of it in pulp chamber.

47. DEVITALIZATION PULPOTOMY
It is two stage procedure involving the use of
paraformaldehyde to fix the entire coronal &
radicular pulp tissue.
The medicament used have a devitalizing,
mummifying, & bactericidal action.

48. TECHNIQUE
First appointment :-
Same as formocresol pulpotomy but place the
paraformaldehyde paste in cotton pellete over the
exposure & seal the tooth for 1 to 2 weeks.
Formaldehyde gas liberates from the
paraformaldehyde permeates through the coronal and
radicular pulp, fixing the tissue.
Second appointment :-
pulpotomy is carried out with the help of local
anaesthesia

49. ELECROSURGICAL PULPOTOMY
Given by mack & dean (1933 )
It is a non chemical devitalizaton technique.
Electrocautery carbonizes and heat denatures
the pulp & bacterial contamination
After amputation of coronal pulp,the pulp
stumps are cauterized through this method

50. Laser pulpotomy
Jeng-fen liu et al in 1999 studied the effect on
Nd:YAG laser for pulpotomy in primary teeth

51. Glutaraldehyde
by kopel (1979 )
Advantages over formocresol
1. Superior fixative property
2. Self limiting penetration
3. Low antigenicity
4. Low toxicity
5. Elimination of cresol
2-5 % concentration

52. Ferric sulphate
It forms a metal protein clot at the surface of
the pulp stump and this act as a barrier to
irritating components of the sub-base

53. Potential Problems With Ferric
Sulphate
• In cases where diagnosis is not accurate and
the remaining pulp is inflamed
– Not a fixative
– Will not be as forgiving as formoc