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

morula

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.A sequence in the implementation of the method:Desensibilisatio pulpaePreparatio cavi dentisAmputatio pulpaeDesinfectio pulpaeMumificatioObturatio Mortal pulpotomy - mummification techniques of pulp therapy

There are two methods:Method of Stransky 3 visits; Formalin-resorcin method 2 visits.Stransky`s methodFirst visit:Diagnosis;Caries removalIn order to protect the child from the pain does not remove the entire caries, but only the one that: gives access to the pulp; is a gingival margin (in second class cavity).Devitalization of teeth by arsenic trioxide

Second visitRemove devitalized arsenic trioxide; Cavity is formed, creating retention; All caries removal;Amputatio pulpae;Desinfectio pulpae;Mumificatio pulpae.Caries removalCaries removal from cavity margins; Last caries removal is from pulp roof.

Roof pulp removingWhen the bur passes through the roof of the chamber a dip is felt;Once this is felt the bur is not taken any deeper but moved sideways to remove the roof of the pulp chamber.

PulpotomyRemove coronal pulp with a large round bur or large excavators;Escavators are safer to avoid perforation in the furcation region.

PulpotomyWith small round bur is removed the pulp from the root in 1-2 mm.

Stransky`s mumification Liquid-A

Rp/Tricresoli 20.0Formalini 60,0M.D.S./A/Liquid - B

Rp/Resorcini 40,0Aq.destil. 50.0M.D.S. /B/Liquid

Rp/Natrii causticiKalii caustici 4,0Aq.dest. 24,0M.D.S./C/Stransky`s methodMix a paste of:ZnOeugenolthymolDense texture-cover with powder Zno

Place the equal drops of liquid A and B close to each other. Mix at the time of placing in the pulp cavityApart from them, on the same plate is placed a drop of liquid C. Mode of operation Dip the cotton pledget in mixed liquids A and B and place it in pulp cavity for 1min.Dried cotton pledget with liquid put in pulp chamber for a second.Fill the periphery of the root canals and all pulp chamber with zinc oxid eugenol and thymol cement for a provisional filling. Third visitCheck for complications. If no the treatment continues.From zinc oxide thymol cement is forming a room for filling.Restoration.Pharmacodynamics of used agentsTricresolformalin :Lipid-soluble compound with the ability to cross biological membranes; Can to precipitate microbial cell proteins ; Violates the lipid metabolism; There are hydrophilic and hydrophobic groups. Rezorcin Has antiseptic activity; Anti-inflammatory activity; The result of mixing trikresol-formalin-resorcin is a bakelite; Potassium sodium hydroxide catalyzed process. Formation of bakelite became in 2 hours.when trikresol-formalin is mixed with resorcinBefore the formation of bakelite started separating paraformaldehyde: disinfecting; bactericidal; dehydrates; coagulate the protein; mummification; Impacting. Zinc oxidAntiseptic: Precipitated proteins of microbial cell; Inhibits enzymes in microorganisms;Dehydrates.Eugenol and thimolEugenol - clove oil;Thymol - oil of thyme herb; Include: Phenols and aldehydes;biologically active substances; Action:Antiseptic;Antiinflammatory;Local anesthetic effect.resorcinol-formalin methodFirst visite devitalisation.Second visit:Caries removal;Cavity preparation;Pulp chamber roof removing;Coronal pulp removing;Radicular pulp (1-2 mm) removingTechniqueOf the sterile plate is placed a drop of 40% formalin and the tip of the spatula with resorcinol crystals - supersaturated solution.Dip the cotton pledget and place it in pulp cavity for 2-5 min. With the remaining amount of the solution and zinc oxide stir a hard paste.Fill periphery of the canals and the base of the pulp chamber, with hard zinc-oxide cement all pulp cavity, then - restorationeffectFormalin - 40%Denature the proteins in MO;Bactericidal action;Virucidal;Sporicidal;Poorly penetrates deeply.Formalin + resorcin = ParaformaldehydAffect microorganisms and toxic degradation; Not interfere with the healing process in periodontal and alveolar bone; Antibacterial action to: Str.haemolyticus Str.Aureus Bactericidal action: Tricresol formalin - 51% sterility Resorcin-formalin - 67% sterilityActionLack of the catalyst;Slowly forming resin;In 24-48 hours is emitted formaldehyde implements its action much longer;The treatment result is more reliable.Periodontitis of primary teethPrevalent chronic processes; Are developed mainly resorptive periodontitis; Almost never observed proliferative forms; Each exacerbation is associated with stormy exudative inflammation and abscess; The process easily becomes chronic and forms a fistula.Treatment of exacerbationsRequired antibiotic treatment;Hydration;Vitamins;Mechanical and chemical treatments of tooth:Providing outflow until the process becomes chronic.When a fistula is currently available In additiontooth of treatment the fistula has to be treated and;Processing to eliminate the epithelial lining of the fistula;Stimulates fistula closing.Treatment of periodontitisIt is used resorcinol-formalin method;First visit - insert formalin-resorcinol; Second visit- Paste of formalin-resorcinol and ZnO; Hard zinc-oxide cement and restoration.Endodontic treatment of the fyrst primary molarFirst primary molar pulpotomy; Second primary molar mortal pulpectomy

Primary molarPulpotomy;Exise tha pulpal tissue to the orifices of the root canals;Fill the pulp chamber with a past.

FillingHard zinc oxid cement;Filling.

Radiographic assessmentPulpotomy.

Results from the application resorcinol-formalin method;Arguments for and against formalin productsArguments against formalin products

Doubt aboutthese argumentsThese relationships have been observed in chronic exposure to high doses observed in industrial production, but not in children treated by said methods; The current problem involves more the production of these drugs than their application; The difficulty comes from the impossibility of obtaining these funds.

Arguments for:conclusionTaking into account:Now we recommend the use of pulpotomy by Stransky and formalin-rezorcinol methodology for treatment of irreversible and open reversible pulpitis