PULP therapy in primary teeth..... pptx

Pulp therapy in primary teeth aims to preserve teeth in the dental arch until they naturally exfoliate

1. Pulp Therapy in Primary Teeth

2. Pulp treatment in primary dentition is generally divided into vital and non-vital pulp therapies and assists in the preservation of pulpally involved primary teeth in the dental arch until the affected tooth naturally exfoliates. Introduction

3. Pulpotomy Types of Pulp Therapy Pulpectomy

4. Pulpotomy Surgical removal of the entire coronal pulp, leaving intact the vital tissue in the canals, followed by placement of a medicament or dressing over the remaining pulp stump in an attempt to promote healing and retention of this vital tissue

5. Carious or mechanical exposure of vital primary teeth and young permanent teeth, where inflammation is restricted to coronal pulp only Indications

6. History of spontaneous pain Swelling Fistula Tenderness to percussion Pathological mobility External/internal root resorption Periapical or interradicular radiolucency Pulp calcifications Pus or exudate from exposures site Uncontrollable bleeding from the amputated pulp stump half root length resorbed. Contraindications

7. Procedure The coronal pulp is amputated, pulpal hemorrhage is controlled, and the remaining vital radicular pulp tissue surface is treated with a long-term clinically-successful medicament. Only MTA and formocresol are recommended as the medicament of choice.

8. Other materials or techniques such as ferric sulfate, lasers, sodium hypochlorite, and tricalcium silicate have conditional recommendations

9. For multisurface lesions After the coronal pulp chamber is filled with a suitable base, the tooth is restored with a restoration If there is sufficient supporting enamel remaining

10. Some studies recommend disinfection of the pulp chamber with 3%–5% sodium hypochlorite (NaOCl) solution prior to drying of the chamber. This is known to dissolve and remove any remnant tissue, debris or dentinal chips which can lead to infection of the radicular pulp. Many studies compared the effects of using 5% NaOCl and physiologic saline for disinfection of the pulp chamber before placement of pulpotomy medicament in the teeth, which showed successful treatment outcomes with MTA.

11. Pulpectomy Removal of the entire pulp and subsequent filling of the canals of the primary teeth with a suitable resorbable material.

12. Indication of Pulpectomy Primary teeth with pulp inflammation extending beyond the coronal pulp Roots and alveolar bone with minimum pathologic resorption Primary teeth with necrotic pulp and or periapical abscess Pus at the clinical pulp exposure site. History of spontaneous pain

13. Evidence of radicular pathologic lesion with or without caries involvement. Alveolar swelling Continuous bleeding even after amputation of the coronal pulp tissue during pulpotomy. Presence of sinus tract. Presence of inter-radicular or periapical radiolucency

14. Contraindication of Pulpectomy Grossly destroyed tooth that is nonrestorable clinically Periradicular involvement extending to the permanent tooth bud, where the risk of damage to the permanent tooth is high. Root resorption—internal or external Extensive mobility Gross bone loss at the apex or at the furcation. Medically compromised children Root length remaining less than 2/3rd Perforation of pulpal floor Any dentigerous or follicular cyst present beneath

15. Serious medical contraindications Patient with systemic illness such as congenital ischemic heart disease. Patient with leukemia. Children on long-term corticosteroids therapy

16. The inflamed or necrotic pulp is removed and access preparation is refined to make sure that entrance to all of the canals is possible and clearly visible. Primary molar roots are usually curved to allow for the development of the succedaneous tooth. P R O C E D U R E

17. Endodontic files are selected and adjusted to stop 1–2 mm short of the radiographic apex, with the preliminary working length estimated according to the preoperative radiograph. The instruments should be slightly bent to adjust to the curvature of the canals, thus preventing perforations on the outer and inner portions of the root

18. The root canals are irrigated with either 0.2 % up to 2 % chlorhexidine solution or with 1 % up to 5 % sodium hypochlorite (limited to one percent sodium hypochlorite according to the AAPD guidelines) Irrigation

19. The root canals are first irrigated with either 0.2 % up to 2 % chlorhexidine solution or with 1 % up to 5 % sodium hypochlorite and then with normal saline The use of sodium hypochlorite in the primary dentition should be performed cautiously since it is a potent tissue irritant and must not be extruded beyond the apex

20. Ideal requirements of material used Must be resorbable Should not interfere with eruption of permanent tooth Should be bactericidal Must be radio-opaque Must be nonirritant Filling/Obturation of Deciduous Root Canals

21. Zinc oxide eugenol – is used without catalyst. Lack of catalyst is used to allow adequate working time. Iodoform paste – Is also being used. It consists of zinc oxide and iodoform mixed into a paste. Its advantages over zinc oxide eugenol are: Potent bactericidal Nonirritant Radio-opaque Chemically active until entirely resorbed Good healing properties Rate of resorption is faster Different materials used

22. Iodoform paste in combination with calcium hydroxide has also been used; it is commercially available as Vitapex and Metapex . These iodoform-containing products resorb if inadvertently pushed beyond the apex, but the rate of resorption of the material from within the canals is faster than the rate of physiological root resorption.

23. Another root canal filling material—a mixture of iodoform, calcium hydroxide, and zinc oxide—is commercially available as Endoflas; in addition, it has eugenol. It is reported to resorb when extruded beyond the apex but resists resorption intraradicularly. Eugenol, one of its constituents, is known to cause periapical irritation.

24. The canals are dried thoroughly using paper points Lentulo spiral, pressure syringe, Jiffy’s syringe, amalgam condensor , local anesthetic syringe, tuberculin syringe, files, etc can be used to carry and deposit the material into the root canal. Methods of Obturation

25. Pressure syringe is one of the best devices used for obturation for the following reasons. Avoidance of air trap Even amount of material is deposited 300 psi force produced allows the use of thick consistency

26. Single or two-visit pulpectomy?

27. Multiple visit pulpectomy (MVP) involves extirpation of the pulp tissue and placement of intra-canal medicament in the first visit followed by obturation in the subsequent visit, if the underlying pathology still persists it may require additional visits. Single-visit pulpectomy (SVP) involves extirpation of pulp and filing the canals short of the apex to a resistance point, after irrigation and final drying obturating material will be placed in same visit

28. Treatment in single visit certainly has many advantages. It is less time‑consuming, resulting in less cost for the patient. In addition, various studies have shown that postoperative pain is equally low when the treatment is performed in single or multiple visits.

29. In fact, an argument could be made that added discomfort due to local anesthetic or trauma from a rubber dam application experienced after a second visit makes single‑visit endodontic treatment less painful than multi‑visit treatment.

30. However, according to RCT study performed in 2016, single‑visit pulpectomy can be considered as a viable option for the treatment of primary teeth with apical periodontitis.

31. Evaluation of Success of pulpectomy No purulent discharge from the gingival margin No abnormal mobility No postoperative pain No further resorption of root (except physiological) Resolution of sinus tract, by 6 month

32. Indirect pulp capping This technique shows some success in teeth with the absence of symptomatology and with no radiographic evidence of pathosis.

33. Indication Deep caries in which the pulpal inflammation has been judged to be minimal and complete removal of caries would probably cause pulpal exposure. Contraindication When there is wide spread inflammation or evidence of periapical pathosis

34. Procedure All the caries on the cavity walls and at the DEJ are removed, due to its closeness to the surface. A large round bur or spoon excavator is used to remove the carious dentin. Round bur in slow speed is preferred, as there is more chance of removal of large segment of dentin with excavator Sedative dressing of calcium hydroxide is placed over the remaining dentin Tooth is then sealed with zinc oxide eugenol and amalgam

35. Direct pulp capping Placement of a medicament or a nonmedicated material on a pulp that has been exposed, in the course of excavating the caries, due to fracture or due to mechanical exposures during routine caries removal

36. Indication Mechanical exposures that occurs following trauma or during cavity preparation which is <1 sq mm, surrounded by clean dentin in an asymptomatic vital deciduous tooth Mechanical or carious exposures <1 sq mm, in an asymptomatic vital young permanent tooth.

37. Contraindication Cariously exposed deciduous teeth Spontaneous pain Swelling Fistula Tenderness to percussion Pathologic mobility Root resorption—external/internal Periapical/interradicular radiolucency Pulp calcifications Profuse hemorrhage from the exposure site Pus or exudate from exposure site.

38. Ideal requirment for materials used for direct pulp capping Stimulate reparative dentin formation Maintain pulpal vitality Bactericidal or bacteriostatic Adhere to dentin Adhere to restorative material Resist forces during restoration placement Must resist forces under restoration during lifetime of restoration Able to be sterilized Radio-opaque Provide bacterial seal Release fluoride to prevent secondary caries.

39. Materials used for direct pulp capping MTA mixing or putty bioceramic putty

40. Thank You Presented By: Dr. Asawer Ahmed Fayyad