Pulp Therapy

• Why is pulpal involvement common in primary teeth?

  • small teeth
  • large pulp chambers
  • failure to diagnose early
  • rapid caries progression
  • failure to treat caries early
• What can cause pulpal exposure in primary teeth?

  ◦ Caries ◦ Iatrogenic - induced unintentionally by a physician ◦ Trauma (rare)
• What can cause pulpal devitalisation in primary teeth?

  ◦ Heavily/repeatedly restored tooth◦ Undiagnosed pulpal exposure◦ Trauma/wear
• What is an alternative to pulp treatment?

  Extraction is the ONLY other option!DO NOT keep under observationDO NOT restore without pulp therapy
• What can lack of appropriate treatment for pulpal involvement lead to?

  - further/prolonged pain- infection- hypoplastic tooth
• What are indications for pulp therapy in primary dentition?

  • Relieve symptoms
  • Remove infection
  • Avoid GA
  • Medical reasons
  • Space maintenance
  • Missing permanent successor
  • Compliant patient
• What are options for pulp therapy in Primary dentition?

  • Vital Pulp: treat reversible pulpitis, maintain viability and function, preserve tooth until exfoliation. Either by pulp capping (direct/indirect), desensitisation pulpotomy, vital pulpotomy
  • Non-vital Pulp: remove inflammed/necrotic pulp tissue, restore/mainting health of periredicular tissues until exfoliation. Non vital pulpotomy
• What is indirect pulp capping and its process?

  Arrests the caries process and promotes pulpal healing

  • L.A. and Tooth isolated (CWR + Rubber Dam)
  • caries removed from cavity periphery with a small amount of carious dentine left directly over the pulp (to avoid carious exposure)
  • Cavity lined with MTA, hard-setting calcium hydroxide, GIC or ZOE cement
  • Success rate high (up to 90%)
• What is direct pulp capping and its process?

  Very small, NON-CARIOUS exposure - pinprick exposure

  • Traumatic / Iatrogenic cause, symptom free
  • maintain pulp vitality
  • L.A. given. Tooth isolated (CWR + Rubber Dam)
  • Cover exposure with MTA or hard-setting calcium hydroxide
  • Success rate moderate (up to 75%)
  • Generally not recommended; rarely indicated
• What is Desensitisation Pulpotomy and when is it indicated?

  Two-stage technique used to devitalise hypersensitive pulp tissueIndicated for a tooth requiring a vital pulpotomy but the child will not accept LA or analgesia cannot be achieved
• What is the 1st part of the procedure for Desensitisation Pulpotomy?

  Steroidal antibiotic paste (eg. Odontopaste) now used Attempt L.A. Tooth isolated (CWR + Rubber Dam) Exposure covered with Odontopaste paste + temp. dressing
• What is the 2nd part of the procedure for Desensitisation Pulpotomy?

  2 WEEKS LATER  Attempt L.A. Tooth isolated (CWR + Rubber Dam) Proceed with Ferric Sulphate (Vital) Pulpotomy and definitive restoration (eg. preformed crown)(If pulp is still sensitive or LA again refused...) Attempt to further enlarge pulpal exposure site and redress with more Odontopaste + temp. dressing Bring patient back 2 weeks later and repeat steps outlined above
• When is a Vital Pulpotomy indicated?

  • large carious / traumatic exposure of vital pulp
  • no previous symptoms / transient pain (ideally)
  • no irreversible pulpitis
  • no clinical or radiographic signs of infection
• What medicaments are used in a Vital Pulpotomy?

  Ferric Sulphate +/- MTA (Mineral Trioxide Aggregate)
• What is a Pulpotomy?

  Removal of the coronal portion of an exposed vital pulp

  Pulp is scooped out and removed from within the tooth’s crown

  
• Why undertake a Vital Pulpotomy?

  - Removes the coronal pulp- Leaves vital radicular pulp- Bleeding arrested with ferric sulphate- Apical part of pulp probably remains vital
• What is Ferric Sulphate?

  15.5% (Trade name ='Astringident') Haemostatic agent Used to control gingival bleeding No fixative effect Success rate of 74-99%
• What is MTA?

  Mineral Trioxide Aggregate

  Consists of:

  • Portland Cement (75%)
  • Gypsum (5%)
  • Bismuth Oxide (20%)
  • Good results (high pH,very biocompatible)
  • Very expensive (£40-50per gram!!!)
• What is the procedure for a Vital Pulpotomy?WE DONT DO AS DHT

  • L.A. given. Tooth isolated (CWR + Rubber Dam)
  • Access pulp chamber and remove coronal pulp
  • Irrigate with water; control bleeding with a wet CWP
  • Apply CWP moist with ferric sulphate to pulp stumps for 15 secs.(Repeat if necessary)
  • Ideally place MTA on pulp stumps, alternative is ZOE
  • Fill cavity with ZOE cement
  • Restore with definitive restoration (ideally preformed metal crown)
• What is a ZOE cement?

  • Zinc oxide-eugenol cement
  • better tolerated by tissue than other dental materials
  • Alleviate pain, are bacteriostatic and antiseptic
  • Good insulators
  • better sealing properties than zinc phosphate cements.
• What is a non-vital pulpotomy?

  Removes accessible pulp remnants, obturate and seal Used as a holding technique only whilst decisions are made regarding a treatment plan
• What medicament is used in a non-vital pulpotomy?

  Calcium Hydroxide
• What are the indications for a non-vital pulpotomy?


  • Exposure of non-bleeding pulp or necrotic/infected pulp
  • Symptoms /signs of: loss of pulpal vitality, periapical periodontitis or acute abscess
  • Spontaneous pain, pathological mobility, fluctuant swelling, radiolucency