For pulp therapy 2

• Is pulpal involvement common in deciduous dentition

  yes
• Why is pulpal involvement common in primary dentition?


  • small teeth 
  • Large pulp chambers
  • Failure to diagnose early
  • Rapid caries progression
  • Failure to treat caries early
• Aetiology of pulp pathology occurs in which 2 ways

  pulp exposure

  • caries
  • iatrogenic
  • trauma

  Pulpal devitalisation:

  • heavily / repeatedly restored
  • undiagnosed pulp exposure
  • trauma
  • wear
• If caries is more than 50% of the dentinal thickness pulp inflammation is more extensive in...

  proximal caries than occlusal
• When caries reaches the marginal ridge most teeth will have...

  pulpal inflammation involves the pulp horns
• Alternative to pulp Tx


  XLA is the only other option, DO NOT keep under obs or restore without pulp Tx
• Lack of appropriate Tx leads to...?

  • further and prolonged pain
  • infection
  • hypoplastic secondary teeth
• Indications of pulp Tx?

  • Relieve symptoms
  • Avoid general anaesthesia
  • Medical reasons
  • Remove infection
  • Missing permanent successor (esp Es with 6s until 5s erupt)
  • Compliant patient
  • Space maintenance
• What are indications of infection?

  • sinus
  • radiolucency in bifurcation
• Contraindications of pulp therapy ?

  • Unrestorable tooth
  • Severe pain or infection
  • Space management
  • Advanced root resorption / close to exfoliation
  • MH - pt at risk of infective endocarditis
  • Poor pt compliance
• Options for pulp therapy in vital pulp ?


  1. pulp capping - direct or indirect
  2. desensitisation pulpotomy
  3. vital pulpotomy
• Options for pulp therapy in non vital pulp ?

  • non vital pulpotomy (DH CAN DO)
  • pulpectomy (DH CANT DO)
• aim of pulp therapy in vital pulp ?

  • Tx reversible pulpitis
  • maintain vitality + function
  • Preserve until exfoliation
• aim of pulp therapy in non vital pulp ?

  • removal of irrev inflamed or necrotic pulp
  • restore / maintain health of periradicular tissue until exfoliation
• Indirect pulp cap

  aim: arrest caries process and promotes pulpal healing

  1. LA + isolation (CWR +- RD)
  2. caries removed from cavity periphery w small amount of carious dentine left directly over pulp to avoid exposure
  3. cavity lined w MTA, hard setting CaOH, GIC or ZOE
• Success rate of indirect pulp capping

  90%
• Direct pulp capping ?

  aim: maintain pulp vitality

  • when there is a v small non carious exposure
  • usually traumatic / iatrogenic and symptom free

  1. LA + isolation (CWR + RD)
  2. cover exposure w MTA or hard setting CaOH
  3. generally not recommended or indicated
• Success rate of direct pulp cap

  75%
• Desensitisation pulpotomy 


  indications: tooth requiring vital pulpotomy but child will not accept LA or analgesia can not be achieved

  • Steroidal antibiotic paste (eg. Odontopaste) now used
  • Attempt L.A. Tooth isolated (CWR + Rubber Dam)
  • Exposure covered with Odontopaste paste + temp. dressing 
• What is a hyperalgaesic pulp

  pulp where analgesia cannot be achieved
• Desensitisation pulpotomy?


  indications: tooth requiring vital pulpotomy but child will not accept LA or analgesia can not be achieved

  • Steroidal antibiotic paste (eg. Odontopaste) now used
  • Attempt L.A. Tooth isolated (CWR + Rubber Dam)
  • Exposure covered with Odontopaste paste + temp. dressing 

  2 weeks later...

  • LA + isolation
  • Ferric Sulphate (Vital) Pulpotomy and definitive restoration (eg. preformed crown)
• When doing desens pulpotomy if 2 weeks later the pulp is still sensitive or LA refused what should be done?

  • Further enlarge pulpal exposure site and redress with more Odontopaste + temp dressing 
  • Bring patient back 2 weeks later and repeat usual steps
• Vital pulpotomy rationale ?


  • removes the coronal pulp
  • Leaves vital radicular pulp
  • Bleeding arrested with ferric sulphate
  • Apical part of pulp probably remains vital 
• Medicaments in vital pulpotomy

  Ferric sulphate +/- MTA
• Indications for vital pulpotomy ?

  • large carious or traumatic exposure of vital pulp
  • no previous symptoms / transient pain (ideally) 
  • no irreversible pulpitis
  • no clinical or radiographic signs of infection 
• Ferri sulphate ?

  • 15.5%
  • Trade name = astringident
  • Haemostatic agent
  • Used to control gingival bleeding 
  • No fixative effect 
  • Success rate of 74-99%
• MTA?

  • Mineral Trioxide Aggregate
  • Good results as very biocompatible, high pH
  • Very expensive ( £40-50 per gram)
• Contents of MTA?

  75% = Portland cement 

  205 = Bismuth Oxide

  5% = Gypsum
• Vital pulpotomy technique?

  1. LA + iso (CWR + RB)
  2. access pulp chamber and remove coronal pulp
  3. irrigate w water + control bleeding with wet CWP
  4. Ferric sulphate moist on CWP to pulp stumps 15 seconds (can repeat)
  5. MTA or ZOE on pulp stumps
  6. Fill cavity w/ ZOE cement
  7. restore w definitive restoration (ideally preformed metal crown)
• non vital pulpotomy ?

  use: a holding technique only whilst decision made regarding Tx plan

  Aim: to remove accessible pulp remnants, obturate and seal

  medication: CaOH
• Indications of non vital pulpotomy ?

  • exposure of non bleeding pulp or necrotic/infected pulp
  • Spontaneous pain
  • Pathological mobility
  • Fluctuant swelling 
  • Radiolucency
  • symptoms of signs of: loss of pulpal vitality, periapical periodontitis and acute abscess