Pulp Therapy in the Primary dentition. Anatomical Features in primary teeth. Dentin: Wide dentinal tubuls ; Additional channels over the pulp horns; Wide dentinal canals above the root delta; Pulp: Maturity level of pulp; Size of the pulp chamber ; Width of the root canals. - PowerPoint PPT Presentation
Pulp Therapy in the Primary dentition
Anatomical Features in primary teethDentin:Wide dentinal tubuls;Additional channels over the pulp horns; Wide dentinal canals above the root delta; Pulp:Maturity level of pulp;Size of the pulp chamber ;Width of the root canals.physiologycal feacures in the primary teethDegree of development of root canals:Formation of root walls;Formation of the apex;physiological resorption:Degree of root degradation;Reactivity of the pulp;Degree of development of the alveolar bone.Priod of development of primary molarspre eruptive periodRoot constructionFunctional periodRoot resorption4 yrs.5 yrsInfected and inflamated dental pulpThere are several reasons for a dental pulp to become inflamed, but the far the commonest is as a sequel to dental caries;Dental caries in primary tooth progresses rapidly to relatively thin enamel and penetrates dentin;The insult from bacterial toxins stimulates the underlying pulp to respond by mounting an inflammatory reaction reversible pulpitis.Etiology of pulp inflamationInfection: For deep cavities; Secondary caries; It is caused by: microorganisms; Microbial toxins; Dentinal degradation products.Pathogenetic mechanisms of pulp inflammation Microorganisms Exo-and endotoxins
Degradation of odontoblastic processes
They are moving through dentine tubules
They are reaching to odontoblasts and nerve receptorsFrom the nerve receptorsIs induced reflective Overcoming reaction protectionProtection
When compensatory mechanisms are running out
InflammationinflammationExudation; Alteration; Proliferation.
Exudative inflammation:alterationAlterationProliferationIf a microbes invade the pulp tissueCausing a massive increase in pulpal response;This is characterised by irreversible inflmmation and tissue necrosis directly adjacent to the site of exposure;Bacteria and their products will progress through the pulp tissue, resulting in irreversible inflammation;The response of pulpal and periodontal tissues to such injury can lead to one of several outcomes:The periradicular tissues may affected (periradicular periodontitis), with eventualy involvement of associated tissue;If the exposure site involves a large area, Hyperplastic pulpitis (pulp polyp) may occur;The tooth may be subject to pathological resorption for example, internal inflammatory resorption. DiagnosticsVisual examination Probe examinationParaclinical examinationsSituation requiring emergencySituation that will soon require emergencyUsed until now classification resulting from the old concept
Acute pulp inflammation:Pulpitis acuta serosa partialis;Pulpitis acuta serosa totalis;Pulpitis acuta purulenta partialis;Pulpitis purulenta totalis;
Chronic pulp inflammation:Pulpitis chronic fibrosa;Pulpitis chronic ulcerosa;Pulpitis chronic granulomatosa.
Old concept for pulpits of primary teeth
The conclusion from the old concept and classification:Features in the clinic of primary teeth pulp inflammationThe most common pulpitis in primary teeth are chronicThe most common chronic pulpitis is fibrosisIn exacerbation of chronic pulpitis of a primary teeth processes are passing very quickly from one phase to another.Current concepts for pulp inflammationContemporary classification of pulpitisReversible pulpitisIrreversible pulpitisContemporary knowledge of the pulp of primary teethTypes of stem cells
Moral problem - the blastocyst is not a human being?
Isolation of stem cells from the pulp of thprimary teethe
Proof of stem cells from the pulp of the primary teeth
The red coloration indicates the presence of nestin; Green staining demonstrated the presence of actin Pulp Therapy in the Primary teethThe treatment plan should be based on specific diagnosed findings, medical status and the child's behavior, social status of the family.Differentiation of reversible from irreversible pulpitisThe most common pulpitis of primary teethReversible - closed asymptomatic pulpitis; Large carious lesions without pulp symptom "pain"; Pulp symptom "pain" is: Spontaneous pain; Night pain; Provoked pain - over 1 min; Occurrence of pain while eating or irritation in carious lesions still does not mean pulp symptom "pain".Criteria for diagnosis "Reversible pulpitis of the primary teeth"clinical findings
Large cavitated carious lesions with:
1.Soften lighter or darker carious dentin;
2. Lack of disclosure of the pulp (pulpitis closed);
3. Cavitation affects closest cusp;
4. The reserved portion is less than of the distance between the tip of the cusp and fissure.Small cavitation, but staining near the cusps, especially at medio-vestibular pulpal horns of the first primary molars
Lack of cusps
Approximal carious lesions covering the entire interproximal wall
Small cavitated carious lesions:
Clinical case of closed asymptomatic pulpitis
Color and cavitation corespond to closed pulpitis
We must distinguish caries and chronic closed Pulpitis
Other clinical cases
Other possible situations
open pulpitisLarge carious lesions with the disclosure of the pulp amongst carious dentin;Open pulpitis.
Diagnosis of reversible pulpitissymptomsradiographic pictureCarious lesion is close to the pulp, a thin and partially demineralized dentin over the pulp horn.
Tests for pulp vitalityClinical findings in the process of removing the carious dentinDifferential diagnosis with decayDifferential diagnosis with irreversible pulpitisirreversible pulpitissymptomsradiographic findingsPartially or completely demineralized dentin over the pulp; Absence of dentin over the pulp horn.
Irreversible pulpitis are exacerbated chronic pulpitisPulp Treatment of primary teethconsensus
of "National Association of Pediatric Dentistry" for the pulp treatment of primary teethRecommended treatment methods
Treatment of reversible pulp inflammation Closed asymptomatic pulpitis - the most common pulpitis of the primary teethThe most appropriate method - indirect pulp capping!
Argument for the effectiveness of indirect coverageIndirect pulp capping technique
First visit First visit The clinical diagnosis is derived from a:1. Comprehensive medical history; 2. Review of past and present dental history and treatment, including current symptoms and chief complaint; 3. Subjective evaluation of the area associated with the current symptoms/chief complaint by questioning the child and parent on the location, intensity, duration, stimulus, relief, and spontaneity; 4. Objective extraoral examination as well as examination of the intraoral soft and hard tissues; 5. If obtainable, radiograph(s) to diagnose pulpitis or ne- crosis showing the involved tooth, furcation, periapical area, and the surrounding bone; 6. Clinical tests such as palpation, percussion, and mobilityClosed Reversible pulpitis
Indirect pulp capping
Appropriate cases for indirect pulp capping
Second stepAll caries is first cleared from the cavity margins with a steel round bur running at a slow speed: From the cavity margins; In gingival basis for interproximal defect (maybe with excavators); Dentin in the area under the enamel-dentine border should be healthy, well-mineralized; Enamel-dentin border must be clearly visible.Third step
Second visitFirst step:Radiographic review;Observe dentin over the pulp - compared to the first X-ray;Expected results: remineralization of demineralized dentin and formation of new tertiary dentin;Second stepHard remineralized dentin
Modern concepts for direct pulp capping in primary teethThis method is not recommended for exposed pulp due to caries of primary teeth from AAPD (2001, 2004, 2009). Not recommended by the British and IAPD.Therefore now this method is not recommended for the treatment of primary teeth.Methods for treatment of irreversible and open reversible pulpitis in primary teethRecommended method pulpotomiyThere are three approaches to the application of this method Techniques employed by IAPDPulpotomy medicament15,5% Ferric sulfate - cotton pledget with medicament placed over the radicular pulp for 15 sec20% (1:5 solution) Formocresol (Buckly) for 5 min;;Calcium hydroxid;
Key pointsFerric sulfateActing on the surface of the radicular pulp;Agglutinate blood proteins and stop bleeding;It is suitable alternative to formocresol.Ferric sulfate
FormocresolTraditionally been used; There have been some concerns about its toxitivity, both locally and systemically;It is used a 1:5 concentration Backly formocresol solution;It is hold 5 min in pulp chamber (1 min);Zinc oxid eugenol;Restore the crown, usually. With a stainless-steel crown.Buckly`s formocresolEqual parts formaldehyde and cresol;Concentration 1:5 is achieved when:Three parts of glycerin;One part of distilled water;Mix in advance;These four equal parts were mixed with one part of the solution to Buckley.Formocresol
gluteraldehyde pulpotomiesGlutaraldehyde:Formaldehyde is a small molecule, a glutaraldehyde - large;Formaldehyde requires a long time for fixation of the tissue - Glutaraldehyde act immediately.The reaction of the glutaraldehyde can not be reversed.Can be an alternative for treatment. (Mineral trioxide aggregate)
Calcium hydroxidA preferred method in the past for treatment of primary teeth pulpitis:Mortal pulpotomyMortal pulpotomy is appropriate because :Age of the children is not suitable for channel instruments;The roots are in resorption;Risk for permanent tooth bud;The method is easy to use;With sufficient reliability till time of physiological tooth change