OUTLINE

Transcription

OUTLINE

OUTLINE
A. The Pulpotomy Technique
Pulp Therapy for Primary Teeth
1- Diagnosis
2- Indications / Contraindications
3- StepStep-byby-step pulpotomy technique
4- Mechanism of action of formocresol
5- Alternatives to formocresol
B. The Pulpectomy Technique
Reporter:
1- Rationale for pulpectomy
2- Indications / Contraindications
3- Root canal filling material
4- Types of pulpectomy techniques
5- Success rates for primary tooth pulpectomies
許修銘
2004/03/30
Introduction
Preservation of primary teeth in the arch
– Management of developing dentition
– Nurturing a positive attitude in
children towards dental health
A. The Pulpotomy Technique
Introduction
Use of pulp therapy to conserve carious
primary teeth
– Preserve pulp involved primary molar
when missing permanent successor
– Prevent possible aberrant habits
– Maintain masticatory function
– Preserve aesthetics
– Future dental attitudes
A pulpotomy is the procedure of
removing coronal part of pulp
tissue, inflamed or infected as
a result of deep caries, &
maintenance of vital radicular
pulp tissue
1
A1A1- Diagnosis
1/5 dilution of
the original Buckley’
Buckley’s formocresol
Primary tooth with deep caries
OD (with GIC)
or
Pulpotomy
NISHIKA
Root canal disinfectant
Cresol
40mL
Formalin 40mL
Ethanol 20mL
A1A1- Diagnosis
A1A1- Diagnosis
The reason for this is that
caries in primary teeth
compromises pulp very early on,
with pulp inflammation setting in
even before pulp is exposed
A1A1- Diagnosis
Hobson (1970)
In over 50% of the primary molars
Loss of marginal ridge
Æ irreversible pulp inflammation
A1A1- Diagnosis
Duggal et al (1999)
–The need for pulp therapy for
most primary molars where
proximal caries has involved the
marginal ridge
–The importance of early
diagnosis of proximal caries with
the use of bitewing radiographs
2
A1A1- Diagnosis
A1A1- Diagnosis
Proximal caries that involved less than half the
intercuspal distance from buccal to lingual cusp
A1A1- Diagnosis
A1A1- Diagnosis
By the time the caries exposes the pulp, the inflammation is irreversible
irreversible
Direct pulp capping is contraindicated
A2A2- Indications
Large caries with substantial loss (≧
(≧1/3 )
of marginal ridge in restorable tooth
Tooth free of radicular pulpitis
At least 2/3 of root remaining
Absence of abscess or fistula
No interinter-radicular bone loss
No evidence of internal resorption
Instances where extraction is C/I
A2A2- Contraindications
An unrestorable tooth
BiBi- or trifurcation involvement
Less than 2/3 of root remaining
Presence of abscess or fistula
Permanent successor close to eruption
Medical contraindications
– Heart disease
– ImmunoImmuno-compromised children
3
A3A3- StepStep-byby-step
Step 1: Administer local analgesia with
the use of a topical analgesic
Nerve block
Step 2: Isolate tooth with rubber dam
Buccal infiltration
Step 3: Remove caries &
determine site of pulp exposure
Step 5: Remove coronal pulp with
large excavator or large round bur
Step 4: Remove roof of pulp chamber
Step 6: Apply FC on a pledget of
cotton wool for 4 minutes
4
Step 7: Remove FC pledget after 4 mins
& check that haemorrhage has stopped
Step 8: Fill pulp chamber with cement
Step 9: Restore tooth with SSC
Step 10: Take a postpost-OP radiograph
FollowFollow-up
–Regularly reviewed both clinically &
radiographically 66-monthly
–Appearance of rarefaction of bone
in furcation area or
a worsening of bone condition
in furcation
usually signifies failure of the procedure
PrePre-OP
PostPost-OP
3M
12 M
5
A4A4- Mechanism of action of FC
FC acts through
aldehyde group of formaldehyde,
formaldehyde,
forming bonds with sideside-groups
of amino acids of both bacterial
proteins & remaining pulp tissue
Both bactericidal & devitalizing
agent
A5A5- Alternatives to FC
Concern about possible toxicity of
FC, both locally & systemically
Alternatives
– Ferric sulphate [Fe2(SO4)3]
– Glutaraldehyde
– Calcium hydroxide
– Other experimental methods
Glutaraldehyde
– Introduced by s’Gravenmade (1975)
– Better fixative agent
– Toxic properties
A4A4- Mechanism of action of FC
Reported
success rate
of FC
pulpotomy
Ferric sulphate [Fe2(SO4)3, 15.5%]
– Excellent haemostatic agent
(ferric ionion-protein complex)
– As effective as FC
– No “fixative”
fixative” effect
Calcium hydroxide
– Poor (around 60%) success rate
– Extensive internal resorption
below amputation
• Allergic reactions
• Eye irritation
6
Other experimental methods
– Electrosurgery
– CO2 lasers
– Enriched collagen solution
B. The Pulpetomy Technique
B1B1- Rationale for pulpectomy
It is true that some primary teeth
do have a complex root
morphology (with many fine
accessory root cancals),
cancals),
but this does not contraindicate
pulpectomy
B2B2- Indications
Irreversible inflammation
extending to radicular pulp
Primary teeth with necrotic pulps
Evidence of furcation pathology
Presence of an abscess
Gain access to the root canals
Remove
Remove as much dead &
infected material as possible
Fill the root canals with a suitable
material
Maintain primary tooth in a nonnoninfected state
B2B2- Contraindications
Unrestorable crown
Advanced pathological root
resorption
Medical contraindications
– Heart disease
– ImmunoImmuno-compromised
children
7
B3B3- Root canal filling material
Being totally resorbed at the
same rate as the roots
– Pure zinc oxide & eugenal mixed
as a slurry
– Maisto’
Maisto’s paste
– Iodoform paste
– Vitapex
Ca(OH)2-Iodoform Mixture
- Vitapex, Endoflas
- Machida (1983): Ca(OH)2-iodoform mixture to
be a nearly ideal primary tooth filling material
1) easy to apply
2) resorbs at a slightly faster rate
than that of the roots
3) has no toxic effects on the
permanent successor
4) radiopaque
B4B4- Single-visit of pulpectomy
Indications
– Presence of inflamed but vital
radicular pulp
– An asymptomatic primary tooth
with necrotic pulp tissue without
any associated acute symptoms,
such as cellulitis
– Presence of a chronic buccal
lesion without any active
discharge or acute symptoms
3 M later
B4B4- Types of pulpectomy
One-stage / single-visit
pulpectomy
Two-stage / two-visit
pulpedctomy
Step 1: Give local analgesia &
isolate tooth with rubber dam
8
Step 2: Remove caries &
identify exposure site
Step 4: Take a diagnostic radiograph
with files in the root canals
Step 3: Remove roof of pulp chamber,
& identify opening of root canals
Step 5: Clean out root canals with H files
& remove remnants of pulp tissue
& irrigate canals with saline
Within 11-2 mm
File lightly
Reaming is not advisable
File to no more than size 30
Step 6: Dry root canals with paper points
& place a pledget of FC in pulp chamber
for 4 minutes
Step 7: Select a spiral root canal filler of
appropriate size
9
Step 8: Mix ZnO & eugenol as a slurry,
Step 9: Fill pulp chamber with cement
& spin it into root canals using
spiral root canal filler
Step 10: Restore the tooth with SSC
Step 11: Take a postpost-op radiograph to
check root filling
B4B4- Singleingle-visit of pulpectomy
FollowFollow-up
–Regularly reviewed both clinically &
radiographically 66-monthly
PrePre-OP
PostPost-OP
6 M later
PrePre-OP
3 M later
PostPost-OP
12 M later
10
92/08/21
(F/U 9M)
PrePre-OP
PrePre-OP
91/11/12
(Root canal filling)
6 M later
92/12/29
(F/U 13M)
PostPost-OP
B4B4- Two-visit of pulpectomy
Spiral root filler
Indications
– Presence of an acute abscess
with or without associated
cellulitis
– Presence of active & persistent
discharge from the root canals
Visit 1: Emergency management of
the acute abscess
– Gaining drainage through carious cavity
or puncturing fistula
– LAÆ
LAÆ Filed to drain
Æ FC pledgetÆ
pledgetÆ IRM
– Antibiotics: 22-dose regimen of amoxycillin
Visit 2: Final root canal filling
– 7~10 days later
– Rubber dam
Æ Access root canals
Æ Pulpectomy procedure
11
B5B5- Success rates
謝謝聆聽
敬請指正
12

OUTLINE

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