Pulp Therapy for Primary Teeth

Pulp Therapy for Primary and
Immature Permanent Teeth
By :
Dr : Najma Mohamed alamami
Alamaminajma@gmail.com

Introduction
The objective of pulp therapy is to maintain the
integrity and health of the teeth and their
supporting tissues . where, type of pulpal therapy
depend on whether the pulp is vital or nonvital.
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‫العمامي‬ ‫نجمة‬
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2

DIAGNOSTIC AIDSIN THE SELECTION OF TEETH FOR PULP THERAPY :
1) History of Pain ((chief complaint , past and present dental history and
treatment ))
2) Physical Condition of the Patient (comprehensive medical history )
3)Clinical Signs and Symptoms (deep carious lesion , extraoral or intraoral
swelling , abscess or a draining fistula , Abnormal tooth mobility , …….etc. ))
Note : Pathologic mobility must be distinguished from normal mobility in
mobility in primary teeth near exfoliation.
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4) Pulp Testing(( electric pulp test, Thermal
tests)), The reliability of the pulp test for the young
young child is questionable because of the child’s
apprehension associated with the test itself. and
inability of child to understand the tests.
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5 ) Radiographic Interpretation
to examine for evidence of periradicular or periapical changes
 is more difficult in children than in adults.
The permanent teeth may have incompletely formed root ends, giving an impression of
periapical radiolucency .
 the roots of the primary teeth undergoing even normal physiologic resorption often
present a misleading picture or one suggestive of pathologic change.
The proximity of carious lesions to the pulp cannot always be determined accurately in the
x-ray film. 15 -1 - 2018
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General Recommendations
 all pulp therapy be performed with rubber-dam or other
equally effective isolation.
Post-operative clinical and radiographic assessment of
Pulp therapy should be performed every six months.
Apexification, reimplantation of avulsions, and
placement of prefabricated post and cores are not
indicated for primary teeth
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General Recommendations
seriously ill children with conditions that render them susceptible to subacute
bacterial endocarditis or those with nephritis, leukemia, solid tumors, idiopathic
cyclic neutropenia, or any condition that causes cyclic or chronic depression of
granulocyte and polymorphonuclear leukocyte counts
should not be subjected to the possibility of an acute infection resulting from
therapy. the treatment of choice of them ((premedication antibiotics + extraction
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reversible pulpitis & irreversible pulpitis
irreversible pulpitis (non vital pulp or necrosis )
reversible pulpitis (vital pulp).
 spontaneous unprovoked toothache.
 a sinus tract, soft tissue inflammation not resulting
from gingivitis or periodontitis.
 excessive mobility not associated with trauma or
exfoliation.
 furcation/apical radiolucency, or radiographic
evidence of internal/external resorption .
(( should be treated with nonvital pulp treatment))
 provoked pain .
 short duration
 relieved with upon the removal of the
stimulus
 without signs or symptoms of irreversible
pulpitis
((should be treated with vital pulp
procedures))
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Classification
of
pulp
therapy
Primary
teeth
Vital pulp therapy( a normal
pulp or reversible pulpitis)
Protective liner
.indirect pulp capping
Direct pulp capping
Pulptomy
One visit vital pulptomy
Two visit pulptomy ,Non
vital pulptomy ( mortal
pulptomy )
Partial pulpectomy
Nonvital pulp therapy
irreversible pulpitis or necrotic
pulp))
Pulpectomy
Young
permanent
teeth
Vital pulp therapy( a normal pulp
or reversible pulpitis)
Protective liner
indirect pulp capping
Direct pulp capping
pulptomy
partial pulpotomy
conventional
pulpotomy
Nonvital pulp therapy
((irreversible pulpitis or necrotic
pulp))
pulpectomy
RCT
open apex.( blunderbuss canal
or funnel- shaped apex ) →
APEXIFICATION
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Vital pulp therapy
( normal pulp)
(reversible pulpitis)
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a) Protective liner (primary or permanent tooth) :
•Definition : protective liner is a thinly-applied liquid placed on the
pulpal surface of a deep cavity preparation, covering exposed dentin tubules, to
act as a protective barrier.
• example of material used: calcium hydroxide, dentin bonding
agent, or glass ionomer cement
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a) Protective liner (primary or permanent tooth).
• Indications : In a tooth with a normal pulp, to minimize injury to the
pulp, promote pulp tissue healing, and tertiary dentin formation, and
minimize bacterial microleakage and/or minimize post-operative
sensitivity.
• Technique : L.A , isolation , caries is remove, a protective liner placed
in the deep areas of the preparation, final restoration ( GI, composite
,amalgam ).
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b) Indirect pulp treatment(primary or permanent tooth).
Definition : a procedure performed in a tooth with a deep carious lesion approximating the pulp
but without signs or symptoms of pulp degeneration.
example of material used: , calcium hydroxide, a dentin bonding agent, zinc oxide eugenol,
or glass ionomer cement .
Indications: is indicated in tooth with
no pulpitis or with reversible pulpitis
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Indirect pulp treatment (primary or permanent tooth).
one-appointment caries excavation
1) L.A , Isolation .
2) The caries surrounding the pulp is left to
avoid pulp exposure and is covered with a
biocompatible material.
3) The tooth is restored with a final restoration
.without a subsequent reentry to remove any
remaining affected dentin .
The step-wise excavation
(( Two steps process))
1) L.A , Isolation
2) The first step is excavation of only the outermost
infected dentin, leaving a carious mass over the
pulp.
3) The second step is the removal of the remaining
caries and placement of a final restoration.
the interval between steps is three to six months,
Note: The decision to use a one-appointment caries excavation or a step-wise technique should be based on the
individual patient circumstances 15 -1 - 2018
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b) Indirect pulp treatment(primary or permanent tooth).
If calcium hydroxide is used, a glass ionomer or reinforced zinc
oxide/eugenol material should be placed over it to provide a seal against
microleakage.
indirect pulp treatment is preferable to a pulpotomy.
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A, Radiograph of the first permanent molar revealed a deep carious
lesion Gross caries was removed, and calcium hydroxide was placed
over the remaining caries. The tooth was restored with amalgam and
was not reentered for complete caries removal for 3 months.
B, Sclerotic dentin can be seen beneath the remaining caries and
the covering of calcium hydroxide (arrows).
C, The tooth was reentered, and the remaining caries was removed.
A sound dentin barrier was observed at the base of the cavity . new
amalgam restoration was placed after complete caries removal.
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c) Direct pulp cap (primary or permanent tooth).
• Definition : When a pinpoint mechanical exposure of the pulp is encountered during
cavity preparation or following a traumatic injury .
Technique: L.A , isolation , biocompatible base such as MTA or calcium hydroxide placed
in contact with the exposed pulp tissue. The tooth is restored with a final restoration .
A, Mesial pulp horn of the mandibular
second primary molar accidentally
exposed during cavity preparation
was covered with calcium hydroxide.
B, Dentinal bridge across the mesial
pulp horn is evidence of pulp healing.
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c) Direct pulp cap (primary or permanent tooth).
Indications:
is indicated in a tooth with a normal pulp following a small
mechanical or traumatic.
The most favorable condition for vital pulp therapy is the small
pinpoint exposure surrounded by sound dentin in the absence of a
hyperemic or inflamed pulp.
Direct pulp capping of a carious pulp exposure in a
primary tooth is not recommended.
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d) Pulpotomy ( primary teeth )
Definition : the complete removal of the coronal
portion of dental pulp , followed by placement of
suitable dressing or medicament that will promote
healing and preserve of tooth vitality ..
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d) Pulpotomy ( primary teeth )
Indications:
in pulp exposure with a normal pulp or reversible pulpitis or after a
traumatic pulp exposure.
When the coronal tissue is amputated, and the remaining radicular tissue is
judged to be vital without suppuration, purulence, necrosis, or excessive
hemorrhage .
there are no radiographic signs of pathologic resorption .
At least 23rd of root length still present .
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d) Pulpotomy ( primary teeth ) vital
pulptomy
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Technique

d) Pulpotomy ( primary teeth ) Technique of vital pulptomy
L.A , and isolation.
Remove of all dental caries the overhanging enamel and roof of the pulp .
amputate the coronal pulp amputate the coronal pulp by sharp discoid spoon
excavator or large bur in low speed H .P .
irrigated pulp chamber with a saline &place moistted sterile cotton pellets on pulp
stump
moistened cotton pellet of formocresol placed in contact with the pulp stumps for 5
minutes.
A thick paste of zinc oxide–eugenol or MTA is placed over the pulp stumps.
The tooth is then restored with a stainless steel crown 15 -1 - 2018
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d) Pulpotomy ( primary teeth ) vital
pulptomy
a cotton pellet moistened with Buckley’s formocresol shoud be
blotted on sterile gauze to remove the excess.
(( care must be taken to avoid contact with the gingival tissues)).
 The pellets are then removed ( check for fixation , brownish
discoloration of pulp stump )
a stainless steel crown(( best restoration for teeth with pulp
therapy ))
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Two visit pulptomy , Non vital pulptomy ( mortal
pulptomy )
Ideally, a non-vital tooth should be treated by pulpectomy or root canal filling
pulpectomy of a primary molar may sometime be impracticable due to
limited patient cooperation. Hence, a two-stage pulpotomy technique is
advocated
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Technique of two visit pulptomy , non vital pulptomy (
mortal pulptomy )
•L.A , Isolation , , Remove of all dental caries , Necrotic pulp is removed
•Moisted cotton pellet placed in Pulp chamber
•Radicular pulp is treated with formcersol dipped cotton pellet
•Seal the cavity with temp. cement for one week
FIRST APPOINTMENT
• Isolation , Remove the temporary dressing & cotton pellet .
• If sign & symptoms persist then repeat the treatment or extract the tooth.
• If no symptoms pulp chamber is filled with antiseptic paste.
• Then it can be restored with stainless steel crown
SECOND APPOINTMENT:-
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e) partial pulpectomy(primary teeth)
 performed on primary teeth when coronal
pulp tissue and the tissue entering the pulp canals
are vital but show clinical evidence of hyperemia,
 there should be no radiographic evidence of
a thickened periodontal ligament or of radicular
disease.
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e) Technique of partial pulpectomy (primary teeth)
removal of the coronal pulp as described for the pulpotomy .
The pulp filaments from the root canals are removed with a fine barbed broach or Hedstrom
file considerable hemorrhage will occur at this point.
(( Care should be taken to avoid penetrating the apex )) .
irrigate tooth with 3% hydrogen peroxide followed by sodium hypochlorite.
dry the canals with paper points.
mix of zinc oxide–eugenol paste and paper points covered with the material
are used to coat the root 15 -1 - 2018
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medicaments of vital pulp therapy
1. buckley’s solution of formocresol
2. gluteraldehyde
3. ferric sulfate
4. electrosurgery
5. calcium hydroxide (( have been used but with less long-term success))
6. mineral trioxide aggregate (( MTA))
7. bone morphogenetic protein .
8. freeze-dried bone.
9. dentin-bonding agents in combination with bonded resin or glass ionomer materials .
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medicament of vital pulp therapy
1) Formocresol was introduced by buckley in 1904
Composition of Buckley’s formula (( formocresol ))
1) formaldehyde ( 19 %)
2) cresol ( 35 %)
3) glycerol ( 15 %)
4) distilled water ( 31%)
 we use The 1:5 concentration of this formula .
 The clinical success related to germicidal action and fixation qualities
rather than to its ability to promote healing.
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2) GLUTARALDEHYDE
Glutaraldehyde is dialdehyde organic compound
.The clinical success rates with glutaraldehyde have ranged
widely, due to :
1. Fixative properties
2. Its bactericidal effect
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Comparison of Pulp tissue reaction to FC
&GA
G
FC
1) Strong protein bonds and superior fixation
2) double aldehyde bonds
3) reactions are irreversible
4) Glutaraldehyde fixes tissue instantly and an excess of
solution is unnecessary
5) Excellent antimicrobial property
6) Large molecular weight so less diffusing Limited
diffusability thus, reducing apical extension of the
material
7) Produce initial zone of fixation that does not proceed
apically (superfacial fix.) Could be replaced by
collagen fibers
8) Treatment conc. 2-5%
1) Weak bond and strong fixation
2) single aldehyde bonds
3) reactions are reversible
4) requires a long reaction time and an excess of
solution to fix tissue.(5min)
5) Has antibacterial property
6) Small molecular weight so easily diffuse High
diffusability with increased apical extension of the
material
7) Broad acidophilic zone of fixation Followed by
pale zone of atrophy Followed by zone of
inflammatory cells extending apically
8) Treatment conc. 1:5
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3) Ferric sulfate
agglutinates blood proteins
controls hemorrhage in the process without clot formation.
ferric sulfate could be a better choice for treating primary teeth needing
pulpotomy (equal results to dilute formocresol but with less toxicity).
Ferric sulfate is available in a 15.5% solution under the trade name of
Astringedent .
Method of app :brushing FS to pulp stumps for 15 seconds
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Objectives of vital pulp therapy
The tooth’s vitality should be preserved.
 No post-treatment signs or symptoms such as sensitivity, pain,
or swelling should be evident.
There should be no radiographic evidence of pathologic external
or internal root resorption or other pathologic changes.
There should be no harm to the succedaneous tooth.
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‫والمحاضر‬ ‫المحاضرة‬ ‫حول‬ ‫استبيان‬
(
‫األولى‬ ‫المرة‬
)
•
‫من‬ ‫للمحاضرة‬ ‫فهمك‬ ‫درجة‬
10
.1
1/10
.2
3/10
.3
7/10
.4
10/10
•
‫المحاضرة‬ ‫سرد‬ ‫سرعة‬
.1
‫بطيئة‬
.2
‫متوسط‬
‫ومقبولة‬
.3
‫سريع‬
.4
‫جدا‬ ‫سريع‬
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‫المحاضرة‬ ‫حول‬ ‫استبيان‬
‫والمحاضر‬
(
‫األولى‬ ‫المرة‬
)
•
‫المحاضرة‬ ‫سرد‬ ‫طريقة‬
.1
‫جدا‬ ‫صعبة‬
.2
‫صعبة‬
.3
‫الصعوبة‬ ‫متوسطة‬
.4
‫وممتعة‬ ‫سهلة‬
•
‫المحاضر‬ ‫أسلوب‬
.1
‫ومفهوم‬ ‫سهل‬
.2
‫تعديل‬ ‫يحتاج‬
.3
‫صعب‬
.4
‫افهم‬ ‫لم‬
‫شي‬
•
‫أخرى‬ ‫مالحظات‬ ‫أي‬
............................................................................................
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Any question ?
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Non vital pulp therapy
( abnormal pulp)
(irreversible pulpitis)
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Pulpectomy of primary teeth .
Definition : the complete removal of the
necrotic pulp from the root canals of primary
teeth and filling them with an inert
resorbable material so as to maintain the
tooth in the dental arch.
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• Indications:
a primary tooth with irreversible pulpitis or necrosis
(e.g., suppuration ).
 tooth treatment planned for pulpotomy in which the
radicular pulp exhibits excessive hemorrhage
The roots should exhibit minimal or no resorption.
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Technique :
1) L.A
2)isolation
3) deroof
of the pulp
chamber
4)The root
canals are
debrided
and shaped
with hand
or rotary
files.
5) irrigation
with sodium
hypochlorite
and/or
chlorhexidin
e ((sodium
hypochlorite
must not be
extruded
beyond the
apex)) and
dry the
canals .
6) pellet
moistened
with
camphorated
monochloroph
-enol (CMCP)
or formocresol
placed in the
pulp chamber.
Then Seal the
chamber with
Z.O.E .
At the second
appointment
7) fill the
canals by non
- reinforced
Z.O.E
or Vitapex
8) restored the
tooth with
SSC
Note:
if the tooth
has been
painful and
there is
evidence of
moisture in
the canals
the canals
should again
be
mechanicall
y cleansed
and the
treatment
repeated
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. A, Pretreatment. B, Immediately after
treatment. C, 10 months after treatment.
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Material of pulpectomy
zinc oxide eugenol paste
 KRI paste are ( zinc oxide and iodoform) .
 Vitapex or metapex (calcium hydroxide
and iodoform)
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• Objectives of pulpectomy :
There should be radiographic evidence of successful filling without
gross overextension or under-filling or pathologic root resorption or
furcation/apical radiolucency
 The treatment should permit resorption of the primary tooth root
and filling material to permit normal eruption of the succedaneous
tooth.
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Failures after pulp therapy
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pulptomy of
permanent teeth
( normal pulp)
(reversible pulpitis)
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Apexogenesis (root formation).
• Apexogenesis is a histological term used to describe the continued physiologic
development and formation of the root’s apex.
• Formation of the apex in vital young permanent teeth can be accomplished by
implementing the appropriate vital pulp therapy (i.e., indirect pulp treatment,
direct pulp capping, partial pulpotomy for carious exposures and traumatic
exposures).
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Apexogenesis (root formation).
Acalcium hydroxide pulpotomy technique. B, Calcified bridge has formed over the vital pulp in the
canals. C, Continued root development and pulpal recession are indicative of continuing pulpal vitality.
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Pulpotomy of permanent teeth
(apexogenesis)
Partial pulpotomy for carious
exposures or for traumatic
exposures (Cvek pulpotomy).
1) inflammation is not widespread
2) 1 to 2 mm of coronal pulp removed .
3) Irrgation by sodium hypochlorite or
chlorhexidine .
4) control hemorrhage .
5) caoH2 or MTA. followed by a layer
of GIR.
6) final restoration is placed.
conventional pulpotomy
1. inflammation is widespread
2. All coronal pulp champer removed .
3. irrgation .
4. control hemorrhage .
5. ca oH2 or MTA . followed by a layer
of GIR.
6. final restoration is placed.
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Pulpotomy of permanent teeth
Indications:
in a young permanent toothwith a diagnosis of normal pulp or reversible
pulpitis.
Objectives:
• The remaining pulp should continue to be vital after pulpotomy.
• There should be no adverse clinical signs or symptoms
• Teeth having immature roots should continue normal root development
and apexogenesis.
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Criteria for success of pulpotomy of
permanent teeth :
Completion of root development.
Absence of clinical signs such as pain, mobility and fistula.
 Absence of any radiographic signs of pathology.
 Some clinicians advise on continuing root canal therapy after the
apex has completely closed to avoid an exaggerated calcific response
that will totally obliterate the canal.
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shallow or partial pulpotomy
→
→
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Conventional pulpotomy
After 20 months (Root completion)
8 months after initial treatment,
after the class IV crown fracture
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pulpectomy of
permanent teeth
( abnormal pulp)
(irreversible pulpitis)
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pulpectomy of permanent teeth
( abnormal pulp) (irreversible pulpitis)
open apex.( blunderbuss canal or
funnel- shaped apex ) The lumen of
root canal is largest at apex and
smallest in the cervical area →
APEXIFICATION
Mature tooth
(closed apex )
→ RCT
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(APEXIFICATION) (Root end closure)
therapy to stimulate root growth and apical repair subsequent to pulpal necrosis in
permanent teeth .
Technique : isolated with a rubber Dam + access opening + instrumentation +
irrigation + drying of the canal + caoH2 & CMCP or caoH2 in a methylcellulose
paste + restoration .
 the treatment paste is allowed to remain for 6 months → presence of a “positive
stop” → gutta-percha filling .
Other technique : after placing caoH2 in the canals for 2 to 4 weeks ,
Root end closure is accomplished with MTA And Gutta percha is used to
fill the remaining canal space.
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(APEXIFICATION)
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57

four successful results of Apexification treatment
1) continued closure of the canal and apex to a normal appearance .
2) dome-shaped apical closure with the canal retaining a blunderbuss
appearance.
3) no apparent radiographic change but a positive stop in the apical
area .
4) positive stop and radiographic evidence of a barrier coronal to the
anatomic apex of the tooth.
15 -1 - 2018
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58

‫والمحاضر‬ ‫المحاضرة‬ ‫حول‬ ‫استبيان‬
(
‫الثانية‬ ‫المرة‬
)
•
‫من‬ ‫للمحاضرة‬ ‫فهمك‬ ‫درجة‬
10
.1
1/10
.2
3/10
.3
7/10
.4
10/10
•
‫المحاضرة‬ ‫سرد‬ ‫سرعة‬
.1
‫بطيئة‬
.2
‫متوسط‬
‫ومقبولة‬
.3
‫سريع‬
.4
‫جدا‬ ‫سريع‬
15 -1 - 2018
‫د‬
.
good luck
59

‫المحاضرة‬ ‫حول‬ ‫استبيان‬
‫والمحاضر‬
(
‫المرة‬
‫الثانية‬
)
•
‫المحاضرة‬ ‫سرد‬ ‫طريقة‬
.1
‫جدا‬ ‫صعبة‬
.2
‫صعبة‬
.3
‫الصعوبة‬ ‫متوسطة‬
.4
‫وممتعة‬ ‫سهلة‬
•
‫المحاضر‬ ‫أسلوب‬
.1
‫ومفهوم‬ ‫سهل‬
.2
‫تعديل‬ ‫يحتاج‬
.3
‫صعب‬
.4
‫افهم‬ ‫لم‬
‫شي‬
•
‫أخرى‬ ‫مالحظات‬ ‫أي‬
............................................................................................
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60

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61

Pulp Therapy for Primary Teeth

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