Pulp therapy in pediatric dentistry

endodontic treatments in pediatric dentistry

1. Pediatric Endodontics in vital tooth

2. CONTENT INTRODUCTION Classification of pulp therapies Indirect pulp capping Direct pulp capping P ulpotomy Apexogenesis

3. Indroduction Importance of maintaining the integrity of the primary dentition are to : Aids in mastication. Maintain esthetics. Prevent possible speech problems. Maintain normal eruption time of the succedaneous teeth. Prevent aberrant tongue habits Preserves pulpally involved primary tooth in the absence of a succedaneous tooth. Prevent the psychological effects associated with early tooth loss.

4. Pulp therapy in pediatric dentistry can be divided into VITAL PULP THERAPY NON VITAL PULP THERAPY PULP CAPPING INDIRECT DIRECT PULPOTOMY Acc. To extent of amputation Partial Complete Acc. To treatment objective Devitalisation Preservation regeration Apexogenesis Partial pulpectomy A pexification

5. INDIRECT PULP CAPPING DEFINITION The procedure involving a tooth with a deep carious lesion where carious dentin removal is left incomplete, and the decay process is treated with a biocompatible material for sometime in order to avoid pulp tissue exposure is known as indirect pulp capping INDICATIONS Teeth with deep caries , which are free from pulpitis. No history of spontaneous pain. No tenderness to percussion. No abnormal mobility No radiographic evidence of radicular disease. No internal or external root resorption detectable radiographically.

6. CONTRAINDICATIONS Teeth with deep caries and symptoms of pulpitis. History of spontaneous pain. Tenderness to percussion. Abnormal mobility. Radiographic evidence of inter cellular bone loss or root resorption.

7. TECHNIQUE OF INDIRECT PULP CAPPING First appointment Use local anesthesia and isolation with rubber dam. ↓ Establish cavity outline with high speed hand piece. ↓ Remove the superficial debris and majority of the soft necrotic dentin with slow speed hand piece using large round bur. ↓ Stop the excavation as soon as the firm resistance of sound dentin is felt. ↓ Periapical carious dentin is removed with a sharp spoon excavator. ↓ Cavity flushed with saline and dried with cotton pellet. ↓ Site is covered with calcium hydroxide. ↓ Remainder cavity is filled with an interim restoration (ZOE cement).

8. Second appointment (6-8 weeks later) Between the appointment history must be negative and temporary restoration should be intact ↓ Carefully remove all temporary filling material. ↓ Previous remaining carious dentin will have become dried out, flaky and easily removed. ↓ The area around the potential exposure will appear whitish and may be soft; which is predentin . Do not disturb this area. ↓ The cavity preparation is washed out and dried gently. ↓ Cover the entire floor with calcium hydroxide. ↓ Base is built up with reinforced ZOE cement or GIC. ↓ Final restoration is then placed

9. DIAGRAM DEPICTING INDIRECT PULP CAPPING

10. B) GROSS CARIES EXCAVATION A) CARIOUS LESION APPROACHING PULP C )MEDICAMENT PLACED E) PERMANENT RESTORATION D) EVALUATION AFTER 6-8 WEEKS

11. DIRECT PULP CAPPING DEFINITION: The procedure in which the small exposure of the pulp, encountered during cavity preparation or following a traumatic injury or due to caries, with a sound surrounding dentin, is dressed with an appropriate biocompatible radiopaque base in contact with the exposed pulp tissue prior to placing a restoration is termed as direct pulp capping. INDICATIONS Small pulp exposures produced during cavity preparation i.e. pinpoint exposures surrounded by sound dentin. When the tooth is not painful, with the exception of discomfort caused by food intake. Minimal or no bleeding from the exposure site.

12. CONTRAINDICATIONS 1. Large pulp exposures. 2. Presence of caries surrounding the exposure site. 3. Excessive bleeding indicates hyperemia or pulpal inflammation . 4. Pain at night. 5 . Spontaneous pain. 6. Tooth mobility .

13. TECHNIQUES OF DIRECT PULP CAPPING- Rubber dam provides only means of working in a sterile environment, so it has to be used. ↓ Once an exposure is encountered, further manipulation of pulp is avoided. ↓ Cavity should be irrigated with saline or distilled water. ↓ Hemorrhage is arrested with light pressure from sterile cotton pellets . ↓ Place the calcium hydroxide ( D ycal), on the exposed pulp with application of minimal pressure so as to avoid forcing the material into pulp chamber. ↓ Place interim restoration . ↓ If treated tooth is asymptomatic for 6-8 weeks a permanent restoration can be carried out.

14. FEATURES OF SUCCESSFUL PULP CAPPING 1. Maintenance of pulp vitality. 2. Lack of undue sensitivity or pain 3. Minimal pulp inflammatory response. 4. Ability of the pulp to maintain itself without progressive degeneration. 5. Lack of internal resorption and intaradicular pathosis.

15. MEDICATIONS AND MATERIAL USED FOR PULP CAPPING -The greatest benefit of Ca(OH)2 is the stimulation of reparative dentin bridge, due to a high alkalinity, which leads to enzyme phosphatase being activated and thus releasing of inorganic phosphate from the blood (calcium phosphate) leading to formation or dentinal bridge. It also has an antibacterial action. -When calcium hydroxide is applied directly to pulp tissue, there is necrosis of the adjacent pulp tissue and inflammation of the contiguous tissue. Compounds of similar alkalinity cause liquefaction necrosis when applied to pulp tissue. -Internal resorption may occur after pulp exposure and capping with calcium hydroxide. -Calcium from Dentin Bridge comes from the blood stream. The action of calcium hydroxide to form Dentin Bridge appears to be a result of low grade irritation in the underlying pulpal tissue after application

16. Denaturated albumin: This protein has calcium binding properties. If a pulp exposure is capped with a protein, the protein may become a matrix for calcifation , thereby increasing the chances of biologic obliteration. Bone morphogenic protein (BMP): The demineralized bone matrix could stimulate new bone formation when implanted to ectopic sites such as muscles. The implications for pulp therapy are immense as it is capable of inducing reparative dentin. Mineral trioxide aggregate (MTA )(1995): it is ash colored powder made primarily of fine hydrophilic particles of tricalcium aluminates, tricalcium silicate, silicate oxide, tricalcium oxide and bismuth oxide is added for radio-opacity. -When compared with calcium hydroxide, MTA produced significantly more dentinal bridging in shorter period of time with significantly less inflammation . - The disadvantage of this technique is that 3 to 4 hours is needed for setting of MTA after placement. -The procedure involves placing MTA directly over the exposure site and sealing the tooth temporarily to allow the cement to harden. The tooth is later reentered and permanently sealed over the set MTA with an etched, dentin bonding agent and composite resin to prevent future bacterial micro leakage.

17. Properties: 1. It is biocompatible material and its sealing ability is better than that of amalgam or ZOE. 2. Initial pH is 10.2and set pH is 12.5. 3. The setting time of cement is 4 hours. 4. The compressive strength is 70 MPA . 5. Low cytotoxity - it presents with minimal inflammation if extended beyond the apex. Action: It has ability to stimulate cytokine and interleukins release from blood cells, indicating that it actively promotes Thicker dentinal bridge Less inflammation Less hyperemia Less pulpal necrosis Dentin bridge formation at faster rate Advantages over Ca( oH )2

18. APPLICATIONS Root end fillings DPC Apexification pulpotomy perforation repairs

19. LIMITATION OF DIRECT PULP CAPPING IN PRIMARY TEETH Caries process or pulp capping material may stimulate the undifferentiated mesenchymal cells that differentiate into odontoblastic cells which lead to internal resorption . High cellular content, abundant blood supply and consequently faster inflammatory response and poor localization of infection are some of the reasons that direct pulp capping is contraindicated in primary teeth. Calcification, chronic inflammation, necrosis and intra radicular involvement.

20. PULPOTOMY DEFINATION-: Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp,followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth. INDICATION-: History of only spontaneous pain . Hemorrhage from exposure sites bright red and be controlled. 1)Acute pulpitis

21. Permanent teeth with pulp exposures either due to trauma or caries when the root formation is incomplete. Permanent teeth with an immature root development but with healthy pulp tissue in the root cannal .

22. CONTRAINDICATION -: History of spontaneous pain Swelling Tenderness to percussion Pathological mobility External/internal root resorption Periapical or interradicular radiolucency Pus or exudate from exposures site

23. Depending upon the size of exposure Partial pulpotomy (shallow, low level or Cvek’s pulpotomy) Cervical pulpotomy (deep, high level total or conventional pulpotomy Classified depending upon the number of visits 1. Single visit pulpotomy 2. Multiple visit pulpotomy

24. A. DEVITALIZATION (SINGLE SITTING) History Sweet (1930)- formulated the technique and was a multivisit formocresol technique. Doyen (1962)- advocated 2 sitting procedure Redig (1966)- Gave 5 minute protocol (partial devitilization ). Formocresol by its chemical nature is the combination of : -Formaldehyde – 19% -Cresol – 35% - Glycerin – 19% -Water FORMOCRESOL PULPOTOMY Formocresol was introduced by Buckley in 1904 and since then a lot of modifications have been tried and advocated regarding the techniques of formocresol pulpotomies Vital Pulpotomy

25. Mechanism of action : it prevents tissue autolysis by bonding to the proteins. This bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without changing the basic structure of protein molecules. Histological changes : by Massler and Mansokhani in 1959. Immediately : Pulp becomes fibrous and acidophilic. After some days : Three zones appear : A broad eosinophilic zone of fixation A broad pale staining zone of atrophy with poor cellular definition Broad zone of inflammatory cells extending apically from the border of the pale staining zone After 1 year : Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year

26. Technique for Pulptomy of the Primary Teeth Anesthetize the tooth and isolate with rubber dam. ↓ Remove all caries using high-speed straight fissure bur without entering the pulp chamber. Remove dentinal roof with a large diamond stone or slow speed round bur for minimal trauma. Enlarge the exposed area and deroof the pulp chamber. Remove any ledges or overhanging enamel with slow speed round bur. Sharp spoon excavators are used to scoop out coronal pulp and pulpal remnants. Clean the pulp chamber with saline and remove all debris. Place a cotton pellet over the pulp stumps to achieve hemostasis.

27. Using a cotton pellet apply diluted formocresol to the pulp for 4 min. ↓ Place a small dry pellet over this to avoid contact of tissues with formocresol. ↓ Remove cotton pellets and check for fixation,brownish discoloration of the pellet as well as the pulp stump is an indicator of fixation. ↓ Place ZOE cement in the pulp chamber ↓ Recall after one week and restore with a permanent restoration if patient is asymptomatic ↓ Place a stainless steel crown

28. DISADVANTAGES OF FORMOCRESOL Local toxicity : There is no actual healing of the pulp and the tooth becomes devitalized . Systemic toxicity : studies have shown that full strength formocresol, is absorbed in to the systemic circulation from the pulpotomy site. Excretion is via the kidney and lungs . Some amount of formocresol remains cell bound in the liver, kidney and lungs that leads to Cytogenic and mutagenic effects due to its ability to denature nucleic acids by forming methylol derivatives and methylene cross links. Damage to succedaneous : it is seen that 1ml of formocresol diffuses through the apical foramen in 3 min.Thus there is high risk for the formation of enamel defects in the permanent successor following the use of formocresol in a primary teeth.

29. ELECTROSURGICAL PULPOTOMY(MACK AND DEAN,1993) It is a non-chemical devitalization, whereas mummification eliminates pulp infection and vitality with chemical crosslinking and denaturation. Electrocautery carbonizes and heat denatures the pulp and bacterial contamination . After amputation of the coronal pulp, the pulp stumps are cauterized through this method . PROCEDURE: Rubber dam isolation and administration of local anesthesia Caries removal with large round slow speed bur Sterile cotton pellets are placed in contact with pulp and pressure is applied to obtain hemostasis

30. The hyfrecator plus 7-797 is set at 40% power and the 705A dental electrode is used to deliever the electrical arc ↓ Cotton pellet is quickly removed and the electrode is placed 1-2mm above the pulpal stump ↓ Electrical arc is allowed to bridge the gap to the pulpal stump for 1 second,followed by a cool-down period of 5 seconds ↓ When the procedure is properly performed,the pulpal stumps appear dry and completely blackened Pulp chamber is filled with ZOE placed directly against the pulpal stumps Final restoration is then placed

31. LASER PULPOTOMY Jeng -fen- liuet al in 1999 studied the effect on laser pulpotomy in primary teeth and noted 100% success with no signs or symptoms, and only one tooth had internal root resorption at the six-month follow up visit

32. PRESERVATION GLUTARALDEHYDE PULPOTOMY It has been widely tested, to replace formocresol. Studies have shown that application of 2-4%produces rapid surface fixation of the underlying pulp tissue. Mechanism of action : Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue. A narrow zone of eosinophilic, stained and compressed fixed tissue is found directly beneath the of application, which blends into vital normal appearing tissue apically. With time, glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue, thus the entire root canal tissue is vital .

33. Procedure -local anesthesia and a rubber dam are applied . -pallets soaked in a 2% buffered freshly prepared glutaraldehyde solution are placed on the wound surfaces and left in place for 3-5 min . -The pellets are removed and a slow-setting zinc oxide-eugenol cement covered with a fast-setting cement is placed and the cavity restored. ADVANTAGES OF GLUTARALDEHYDE OVER FORMOCRESOL : it is bifunctional agent , which allows it to form strong intra and intermolecular protein bonds leading to superior fixation by cross linkange . 15-20 times less toxic than formocresol. demonstrates less systemic distribution. it is low tissue binding, readily metabolized, eliminated in urine and expired in gases-90% of the drug is gone in 3 days.

34. DISADVANTAGES Neither the optimal concentration,nor the amount of time period of application has been coclusively established. 2. Failure rate is more than formocresol 5 . mutagenicity-Glutaraldehyde does not reach the nucleus of the liver cell. 6 . antigenicity-less as compared to formocresol. 7 . Less dystrophic calcification in pulp canals. 8 . Diffusability is limited, thus reducing the apical extension of the material.

35. Ferric sulphate The ferric sulphate the most suitable alternative to formocresol in the next few years. ferric sulphate can be used as a suitable alternative for those concerned about the toxicity of formocresol It is a non aldehyde haemostatic compound (1)astringent; (2)forms a ferric ion-protein complex that mechanically occludes capillaries; (3) less inflammation than formocresol (4) 92.7% radiographic success rate. (5)100% clinical success (6)root resorption is not accelerated (7)internal resorption similar to formocresol ,no systemic or local side effects

36. Regeneration An ideal pulpotomy treatment should leave the radicular pulp vital , healthy and completely enclosed within an odontoblast-lined dentin chamber. CVEK’S PULPOTOMY This is called as calcium hydroxide pulpotomy or young permanent partial pulpotomy. This was proposed by Mejare Cvek in 1993. Indications It is indicated in young permanent teeth with incomplete root information and the radicular pulp is judged vital by the clinical and radiographic criteria.

37. PROCEDURE : Application of rubber dam ↓ All carious material is removed with excavators or slow speed round bur. ↓ Coronal pulp removed , to perform a pulpotomy. ↓ After arrest of the hemorrhage , Ca(OH)2 is applied to the exposed pulp , ensuring that there is no blood clot. ↓ The cavity is then sealed with temporary restorative material. A tooth should remain symptom free at recall and radiograph should show formation of a secondary dentine bridge. ↓ Then permanent restoration with amalgam is done.

38. Apexogenesis 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 teeth having mechanical or traumatic pulp exposure.

39. Indication Traumatic luxation Carious exposure Fractured tooth with pulpal exposure Material used Ca(OH)2(calcium hydroxide) or MTA((mineral trioxide aggregate) Contraindications • Severe crown-root fracture that requires intraradicular retention for restoration • Tooth with an unfavourable horizontal root fracture (i.e., close to the gingival margin) • Carious tooth that is unrestorable • Necrotic pulp APEXOGENESIS

40. Apexogenesis

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