Vital Pulp Therapy

Vital Pulp Therapy
Outline
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Introduction into the objectives of pulp therapy
Morphology of the root canal
Clinical Assessment of the pulp status
Vital pulpotomy medicaments
Vital pulpotomy procedure
Conclusion
Introduction
• Despite advances in understanding about how to
prevent dental caries and the importance of
maintaining the natural dentition, many teeth are
still lost prematurely.
• The primary objective of pulp treatment is to
maintain the integrity and health of oral tissues.
Introduction
Other reasons
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Reduce the likelihood of mesial drift, supraeruption of opposing teeth and the resultant
malocclusion.
Aid mastication.
Preserve a pulpally involved primary tooth
especially in the absence of a succedaneous tooth.
Prevent possible speech problems.
Introduction
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Maintain aesthetics.
Prevent aberrant tongue habits
Prevent the psychological effects associated
with early tooth loss.
Maintain normal eruption time of the
succedaneous teeth.
Pulp Function
• Before attempting pulp therapy in the primary dentition,
the clinician should be familiar with the basic differences
between primary and permanent root canal anatomy.
• The pulp performs five major functions namely
induction, formation of tissues, provide nutrition, ensure
defense following injury and provide sensation.
Pulp Function - 2
Induction
• Pulp participates in the induction and
development of odontoblasts and dentine,
which, when formed, induce enamel
formation.
Pulp Function - 3
Formation
• Odontoblasts form dentine continuously
throughout the life of the tooth.
• Odontoblasts can also form a unique type of
dentine (secondary and tertiary dentine) in
response to injury, such as occurs with caries,
trauma, and restorative procedures.
Pulp Function - 4
Nutrition
• The pulp supplies nutrients that are
essential for dentine formation and
hydration.
Pulp Therapy in Pediatric Dentistry
Introduction
Pulp Function
-5
• Pulp functions (continued)
– Nutrition
Defense
• Via dentinal tubules, pulp supplies nutrients that are
essential for dentin formation and hydration.
• Odontoblasts form dentine in response to injury,
particularly when the original dentine thickness
– Defense
• Odontoblasts
form dentin in
injury,wear,
has
been compromised
byresponse
caries,totooth
particularly when the original dentin thickness has been
trauma,
or restorative
procedures.
compromised
by caries, wear,
trauma, or restorative
procedures. Pulp also has the ability to elicit an
• Pulp
also hasand
theimmunologic
ability to response
elicit anininflammatory
inflammatory
an attempt to
neutralize
or eliminate
invasion of
by cariesand
immunologic
response
in dentin
an attempt
to
causing microorganisms and their byproducts.
neutralize or eliminate invasion of the pulp by
caries-causing microorganisms and their by
products.
Pulp Function - 6
Sensation
• Through the nervous system, pulp transmits
sensations, also mediated through dentine, to
the higher nerve centers.
Pulp Therapy in Pediatric Dentistry
Pulp Content
Introduction
• Characteristics of Pulp Tissue
• Lymph vessels
• Blood vessels
– Most
similar
to connective tissue
• Nerve
tissue
– Tremendous
healing potential
• Undifferentiated
mesenchymal cells
• Fibroblasts
– Apical
vascularity is important to healing potential
• Defense cells (neutrophils, lymphocytes, and
– Coronal tissue is more cellular
macrophages)
– Apical
tissue is more fibrous
• Odontoblasts
– Pulp
becomes more fibrotic with age
• Osteoclasts/Odontoclasts
Pulp Content
The healing potential of healthy pulp tissue is a
function of:
• The vascularity of the pulp.
• The absence of cariogenic and inflammatory
bacteria.
• The cellular/structural integrity of the
pulp/dentin/enamel complex.
• The absence of a chemical and/or thermal insult.
Morphology of The Root Canal
• The root canals of anterior primary teeth are
relatively simple, have few irregularities, and are
easily treated endodontically.
• The root canal systems in the posterior primary teeth
contain many ramifications and deltas between
canals making thorough debridement quiet difficult.
Pulp Therapy in Pediatric Dentistry
Morphology
ofThe
TheRoot
Root
Canal
Morphology of
Canal
• Simultaneously, secondary dentin is deposited within the root
canal system.
• The deposition produces variations and alterations in the number
• Generally,
there
is only
one
canal
present
in
and
size of the root
canals,
as well
a many
small
connecting
branches
and lingual
aspects
of the
the canals.
eachbetween
root ofthe
thefacial
primary
molars
when
• Accessory
canals,of
lateral
canals,has
and been
apical ramifications
formation
the roots
completed.of the
pulp may be found in 10 to 20% of primary molars.
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• The primary tooth root will begin to resorb as
Primary teeth have characteristic ribbon-like radicular pulp.
soon as the root length is completed.
Primary
molar
roots arecauses
widely divergent
and curved
to allow for
•
The
resorption
the
position
of
the
the development of the succedaneous tooth.
apical foramen to change continually.
Morphology of The Root Canal
• The maxillary primary molars may have two to five
canals, with the palatal root usually rounder and
longer than the two facial roots.
• In the mesio-facial root, two canals occur in
approximately 75% of the primary maxillary first
molars and 85 to 95% of primary maxillary second
molars.
Pulp Therapy in Pediatric Dentistry
Morphology
ofThe
TheRoot
Root
Canal
Morphology of
Canal
• The thickness of enamel and dentin coronal to
chamber
is also
thinner
in a primary
• the
Thepulp
primary
mandibular
first
and second
molars
tooth.
usually have three canals which generally
correspond to the external root canal anatomy.
• • Since
the distance
the occlusal
Approximately
75% offrom
the mesial
roots in surface
and
the floor
of the
pulp chamber
primary
first molars
contain
two canals;is much
shorter
in a permanent
tooth,
whereasthan
in primary
second molars,
85%care
of themust
be
taken
when
making
access opening into
mesial
roots
contain
twoan
canals.
the pulp chamber to prevent perforation into
the furcation area.
Clinical Assessment of Pulp Status
History of Pain
Three important factors to consider
• Duration (how long does it hurt?)
• Frequency (how often does it hurt?)
• Location (where does it hurt?)
Clinical Assessment of Pulp Status
Extent of Lesion
• Location
• Colour
Mobility
• Differentiate between physiologic root
resorption and pathologic root/bone loss
Soft tissue swelling
Lymphadenopathy
Pulp exposure - Hemorrhagic versus Necrotic
Clinical Assessment of Pulp Status
Types of Pain and Pulp Status
• Irreversible (indicated for non-vital pulpotomy)
• Spontaneous/Non-stimulated
• Nocturnal
• Constant
Clinical Assessment of Pulp Status
Reversible (indicated for vital pulpotomy)
• Pain stimulus on thermal, chemical irritation
• Intermittent in nature
Clinical Assessment of Pulp Status
Pulp Testing
• Percussion is most reliable in primary teeth
• Thermal sensitivity testing is reliable in primary
teeth.
• Electrical pulp testing is NOT reliable in primary
teeth due to the non-reliability of patient’s
response.
Clinical Assessment of Pulp Status
Radiographic Examination
• Pathologic bone resorption.
o In the presence of infection, bone is destroyed.
o The bone destruction is seen in the furcation area
of the tooth.
o With chronic and long-standing infection,
resorption can become extensive involving the
apical areas as well.
o Bone resorption is indicative of pulpal necrosis and
non-vitality of the associated tooth.
Clinical Assessment of Pulp Status
Other radiographic evidence of pulpal pathology:
• Internal/External resorption.
• Calcific changes.
• Widened periodontal membrane/ligament.
Clinical Assessment of Pulp Status
• Histological changes
There is a poor correlation between clinical
symptoms and histologic pulp status.
General Principles of Treatment
• Painless technique is essential. Adequate
anaesthesia is compulsory in order to gain the
child’s cooperation.
• Use rubber dam to maintain dry sterile field,
prevention of aspiration or swallowing of dental
instruments, isolate tooth and prevent soft tissue
injury.
• Infection control principles must always be applied.
• Consider the restorability of affected tooth.
Vital Pulpotomy
A procedure in which the non vital coronal pulp (or
part of it) is amputated, and a medicament is placed
over the radicular pulp to help maintain its vitality.
Vital Pulpotomy
Indications
• Mechanical or carious exposure of pulp
• Inflammation limited to coronal pulp
• Absence of spontaneous pain
• Absence of swelling or alveolar abscess formation
Vital Pulpotomy Medicaments
Pharmacologic agents:
• Formocresol
• Calcium hydroxide (not used for primary teeth)
• Glutaraldehyde
• Ferric sulphate
• Mineral trioxide aggregate (MTA)
• Paraformaldehyde for devitalization pulpotomy
Vital Pulpotomy Medicaments
Non pharmacologic agents
• Laser
• Electrosurgery
Formocresol
• Formocresol has been the ‘gold standard' material
for vital pulpotomy many decades
• Introduced by Buckley 1904.
• Clinically emphasized by Sweet in 1930
• Contains 19% formaldehyde, 35% cresol, 15% water
and glycerin
Formocresol - 2
• Buckley formocresol comes as a 20% concentrated
solution.
• Should be diluted as a 1:5 dilution before use.
• This is done by adding 3 parts of glycerin to 1 part of
distilled water; then 1 part of formocresol to 4 parts
of diluent.
• Success rate ranges from 70-97%.
Formocresol - 3
• Despite its efficacy, there are doubts about its safety.
• Suspected to be mutagenic, cytotoxic, carcinogenic
thus posing threat to humans.
• IACR 2004 classified formaldehyde as carcinogenic to
humans.
• Strong but not sufficient evidence of formocresol
causing leukemia and cancer of the paranasal sinuses
(Zarzar 2003).
Formocresol - 4
• Suitable material replacement for formocresol
include MTA, glutaraldehyde, ferric sulfate, BMP,
osteogenic protein, bioactive glass.
• Non-pharmacologic haemostatic techniques e.g
Laser and electro surgery.
• These replacement are equally effective without the
side effects of formocresol.
Formocresol Pulpotomy Procedure
Give Local anaesthesia.
Isolate tooth with rubber dam.
Use No 330 bur to create your cavity outline.
Remove all carious dentine and the roof of the pulp
chamber with a slow speed round bur.
• Amputate the coronal pulp with a slow speed round
bur or a spoon excavator.
• Irrigate coronal pulp chamber with normal saline.
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Formocresol Pulpotomy Procedure
• Place a moisten cotton pellet on the orifice of the
canals to achieve haemostasis for between 3-5
minutes.
• Place cotton pellet moistened with formocresol on
pulp stump for 5 minutes.
• The pulp stump should appear blackish brown.
• If there is bleeding after use of formocresol, check
for residual pulp tissue otherwise indicative of
irreversible pulpitis.
Formocresol Pulpotomy Procedure
• Remove the formocresol moistened cotton pellet.
• Cover the radicular root stump with medicament
containing a drop of formocresol, a drop of eugenol
mixed with eugenol powder.
• Fill the pulp chamber with zinc oxide eugenol.
• Restore with stainless steel crown
• Recall patient for follow-up.
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Apexogenesis
• Indicated in a vital young permanent tooth with
pulpal exposure whose root apex(apices) is (are)
still open.
• Infection must be limited to the coronal pulp
tissue.
• Ca(oH)2 pulpotomy is done to facilitate the
completion of apex formation
Apexogenesis
Apexogenesis:
• Preserves pulp vitality
• Results in the formation of dentinal bridge where
Ca(oH)2 is placed on the radicular pulp.
• Ensures vitality of the radicular pulp tissue is
maintained
• Normal apical end of root formation continues
and its closure ensured.
Conclusion
• Pulp therapy in children is time consuming but
rewarding.
• A good history, clinical and radiographic
examinations are very important in diagnosis and
treatment.
• Good understanding of material choices is also very
important.
Quiz 1
Indications for vital pulpotomy:
• Mechanical or carious exposure of pulp
• Inflammation limited to coronal pulp
• Presence of spontaneous pain
• Absence of swelling or alveolar abscess formation
Quiz 2
Pharamcological agents for vital pulpotomy:
• Formocresol
• Glutaraldehyde
• Ferric sulphate
• Laser
• Electrosurgery
Quiz 3
Steps for formocresol pulpotomy include:
• Remove carious tissue before mechanical exposure
of coronal pulp tissue
• Extirpate the coronal pulp tissue using a spoon
escavator or slow round bur
• Remove the radicular pulp tissue also
• Ensure placement of stainless steel crown.
THANK YOU
Acknowledgement
• Slides were developed by Olubukola Olatosi of the
Department of Child Dental Health, University of
Lagos with inputs from Morenike Ukpong of the
Obafemi Awolowo University Ile-Ife.
• The slides were developed and updated from
multiple materials over the years.
• We hereby acknowledge that many of the materials
are not primary quotes of the group.
• We also acknowledge all those that were involved
with the review of the slides.