3. Signs & Symptoms
ā¢ History of pain
ā¢ Visibly carious defect
ā¢ Presence of
ā¢ Irritable behavior
provoked or
ā¢ Difficulty chewing
spontaneous pain
ā¢ Tooth may be tender
to percussion
ā¢ Radiolucency
4. Anatomical Challenges
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
Small teeth, large pulp chambers
Thinner enamel and dentin
Wider, shorter dentinal tubules
Variations in pulp size and shape
Slender pulp horns
Shallow pulp chambers
Large apical foramina
Increased number of accessory canals and foramina
Roots flare outwards
Roots are narrower mesiodistally
10. Caution
ā¢ Children tend to become anxious
ā¢ Possibility of false positive or false negative
ā¢ Recently traumatized tooth may not give a
reliable response
12. Indirect Pulp Therapy
ā¢ āA procedure in which material is placed over
a thin layer of carious dentin that, if removed,
might expose the pulp.ā
ā¢ Recommended for teeth with deep carious
lesion but no pulpal degeneration.
14. Indications
ā¢ Mild discomfort from chemical or thermal
stimuli
ā¢ Absence of spontaneous or nocturnal pain
ā¢ Absence of lymphadenopathy
ā¢ Normal gingiva
ā¢ Normal tooth color
ā¢ Normal lamina dura and PDL space
17. Technique
ā¢ Provide local anesthesia and isolate the tooth
ā¢ Assess the preoperative appearance of the
lesion
ā¢ Remove all infected tissue
ā¢ Leave behind hard discolored dentin
ā¢ Cover with calcium hydroxide liner
ā¢ Re-enter after 6-8 weeks and place
restoration
18.
19. Factors affecting Success
ā¢ Signs and symptoms consistent with
reversible pulpitis
ā¢ Absence of other clinical or radiographic
lesions
ā¢ Complete removal of caries except where
exposure would occur
ā¢ Excellent seal and prevention of bacterial
contamination
20. IPT vs Direct Pulp Capping?
ā¢ DPC is not recommended for carious pulp
exposure
ā¢ Higher risk of failure in primary dentition
ā¢ Al-Zayer, Straffon, Feigal and Welch found
95% success rate with IPT
ā¢ Nearly all teeth exfoliate at normal times
following IPT
22. Indications
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
Pulp exposure greater than suitable for IPT
No radicular pulpitis
Presence of pain (vital pulp)
Tooth has two-thirds of its root length
No evidence of internal resorption
No bone loss, fistulas, or abscesses
23. Contraindications
ā¢ Root resorption exceeds 1/3rd of root length
ā¢ Non-restorable crown
ā¢ Highly viscous, sluggish or absent hemorrhage
at radicular orifices
ā¢ Marked tenderness to percussion
ā¢ Excessive mobility
ā¢ Persistent tooth ache and coronal pus
24. Technique
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
Anesthetize and isolate with a rubber dam
Remove all superficial caries
Enter the pulp chamber with a no.330 bur
Amputate pulp with either a spoon excavator or round bur
(leave radicular pulp intact)
Achieve hemostasis with cotton pellets
Dip cotton pellet in formocresol (1:5 dilution)
Place over pulp stumps for 5 minutes
Provide base of ZnOEugenol over amputation sites and
condense over pulpal floor
Use a second layer to fill the access opening
Final restoration: preferably, stainless steel crown
32. Success (and failure)
ā¢ Clinical success rate of 80-95%
ā¢ Drops to 74-88% if radiographic results included
ā¢ Failure if:
ā
ā
ā
ā
ā
Pain
Swelling
Fistula
Periapical or inter-radicular radiolucency
Internal or external resorption
ā¢ 38% of pulpotomized teeth exfoliate prematurely
33. Alternative Materials
ā¢ Preservation: corticosteroids, gluteraldehyde,,
ferric sulphate, electrosurgery, lasers
ā¢ Remineralization: TGF-b, freeze dried bone,
mineral trioxide aggregate
34. Formocresol vs Ferric Sulphate?
ā¢ Peng, Ye, et al found equivalent success rates
ā¢ Ferric sulphate produces local, reversible
inflammatory response
ā¢ No toxic or harmful effects documented in
literature since 1856
ā¢ Formocresol is cytotoxic, and systemically
distributed; systemic distribution has been shown
to cause immune sensitization, mutations and
cancer in animal studies
ā¢ Formocresol is a known human carcinogen
35. Non-vital Pulp: Pulpectomy
ā¢ Removal of non-vital cariously exposed pulp
chamber roof and contents
ā¢ Often preferred for primary anteriors
ā¢ Especially difficult for primary molars
38. Technique
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
Treat pathologies such as abscess first
Once resolved: provide anesthesia and isolate
Remove all caries
Access the pulp chamber carefully
Remove pulp
Irrigate with saline, fill canals with ZnO paste
Fill pulp chamber with cement
Restore
39. Some points about Obturation
ā¢ Properties of ideal root filling material for primary
teeth:
ā Resorbable, antiseptic, non-inflammatory, non-irritant,
radiopaque, easy to use, does not discolor tooth
ā¢ No such material exists; CaOH+iodoform comes
closest
ā¢ Gutta percha or silver points are contraindicated
as they interfere with physiologic primary root
resorption
ā¢ ZnOEugenol and CaOH with iodoform are used
40. Obturation Techniques
for ZnOEugenol
ā¢ With a reamer:
ā A thin mix is made and carried into the root canals with a no.15
or no.20 reamer
ā The reamer is then:
ā¢ Rotated clockwise and simultaneously tilted 10-15 times (facilitates
entry)
ā¢ Moved vertically and simultaneously tilted 10-15 times (facilitates lateral
condensation and coating of canals)
ā¢ Withdrawn anticlockwise 5 times (material stays inside the canal)
ā¢ With wet cotton: similar to above but a squeezed wet
cotton pellet is used to condense the material
ā¢ With a lentule-spiral: material is taken inside the canal with
a lentulo or lentulo spiral
ā¢ Endodontic pressure syringes, jiffy tubes and tuberculin
syringes may also be used
41. Obturation Techniques
for CaOH with Iodoform
ā¢ Canal is dried and an injectable syringe is
loaded
ā¢ The syringe is taken inside the canal; the
material is extruded slowly while the syringe is
withdrawn
ā¢ This technique may also be used with Calcium
preparations lacking iodoform
42. Final Restoration: Stainless Steel
Crown
ā¢ āPrefabricated semi-permanent restorations
for both primary and permanent teeth.ā
ā¢ Available in a range of sizes from 2 to 7.
43. Indications
ā¢ Extensive carious lesion
ā¢ Developmental defects, to prevent loss of
vertical dimension
ā¢ Following pulpal therapy in primary teeth
ā¢ Severe bruxism
ā¢ As abutments
ā¢ In fractured primary teeth
ā¢ Correction of anterior single tooth crossbite
45. Technique
ā¢ Anesthetize the patient and isolate the tooth
ā¢ Reduce the occlusal surface by 1.5-2.0 mm with a
no.69 or 169 bur
ā¢ Round all sharp angles by moving the bur at 45
degrees
ā¢ Reduce the proximal surfaces
ā¢ Select a crown, seat it and mark its extension
ā¢ Trim the crown to below the mark
ā¢ Contour and crimp it
ā¢ Cementation is frequently done with glass ionomer
ā¢ Check the margins
46. Benefits
ā¢ Longer life than Class II amalgam restoration
(withstand fracture, donāt need to be
repeated)
ā¢ More cost-effective
ā¢ Ease of delivery
ā¢ Less time-consuming than multi-surface
amalgam restorations
47. Hall Technique
ā¢ A unique and minimally invasive approach to
managing deep carious lesions in deciduous
dentition by cementing metal crowns over them
ā¢ Pioneered by Dr.Norma Hall; published in 2006 as
a retrospective study
ā¢ Does not require local anesthesia, tooth
preparation or even caries removal!
ā¢ Requires careful case selection, a high level of
clinical skills, and excellent patient management
48. A Radical New Way of Thinking
ā¢ Instead of removing bacteria, it changes their
cariogenic potential by cutting them off from
substrates
ā¢ What about soft dentin? Natural
remineralization once the carious process
arrests
ā¢ The dentinal pulp complex has greater
reparative potential when subject to caries
than previously thought
49. Exclusion Criteria
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
Irreversible pulpal involvement
Insufficient tooth tissue left to support crown
Lack of patient co-operation
Patient at risk of bacterial endocarditis
Aesthetic concerns
When there is no need for a Hall crown:
ā Teeth close to shedding
ā Tooth more easily treated with partial caries removal
ā Several non-cavitated lesions better treated with a
fissure sealant
ā Cleanable, arrested lesion
51. Extraction
ā¢ Indications:
ā
ā
ā
ā
Infectious process canāt be arrested
Lack of bony support
Lack of root support
Inadequate tooth structure remaining for
restoration
ā Patient has medical factors that contraindicate
saving the primary tooth (for eg: congenital
cardiac defects, immune suppression)
53. References
ā¢
ā¢
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ā¢
āPediatric Dentistry: Principles and Practiceā by MS Muthu, 2nd edition
Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB: Indirect pulp treatment of primary posterior teeth: a
retrospective study (2003)
Marchi JJ, de Araujo FB, Frƶner AM, Straffon LH, Nƶr JE: Indirect pulp capping in the primary
dentition: a 4 year follow-up study (2006)
Ribeiro CC, de Oliveira Lula EC, da Costa RC, Nunes AM: Rationale for the partial removal of carious
tissue in primary teeth (2012)
āNew Options for Restoring a Deep Carious Lesionā by Dr. Robert Rada
ļ»æ
(http://www.dentistrytoday.com/dental-materials/8820-new-options-for-restoring-a-deep-cariouslesion)
Farooq NS, Coll JA, Kuwabara A, Shelton P: Success rates of formocresol pulpotomy and indirect
pulp therapy in the treatment of deep dentinal caries in primary teeth (2000)
Vij R, Coll JA, Shelton P, Farooq NS: Caries control and other variables associated with success of
primary molar vital pulp therapy (2004)
āManagement of Deep Carious Lesions in Childrenā by Dr. Nevine Waly
(http://www.scribd.com/doc/88316496/Management-of-Deep-Carious-Lesions-in-Children)
āPulp Therapy in Primary and Young Permanent Teethā by Dr. Steven Chussid
(http://www.columbia.edu/itc/hs/dental/d7710/client_edit/Pulp_Therapy.pdf)
Casas, Kenny, Judd and Johnston: Do we still need formocresol in pediatric dentistry? (2005)
Peng L, Ye L, Guo X, Tan H, Zhou X, Wang C, Li R: Evaluation of formocresol versus ferric sulphate
primary molar pulpotomy: a systematic review and meta-analysis (2007)
The Hall Technique: A Userās Manual (University of Dundee;
http://www.scottishdental.org/resources/HallTechnique.htm )