#DEN4001
#D4/S1/W6
#Paediatrics
#Endo

Decisions regarding vital pulp therapy

VItality status

• normal pulp
  • symptom free, responds regularly to vitality tests
  • no signs of inflammation or distress
• reversible pulpitis
  • pulp with inflammation capable of healing
  • inflammation that can be resolved with appropriate healing
• symptomatic or asymptomatic irreverisble pulpitis
  • inflammation of vital pulp that cannot heal
  • inflammation beyond reversible treatment
• necrotic pulp
  • pulp tissue has undergone cell death
  • complete loss of vitality, necessitating appropriate intervention

diagnosis process includes

• comprehensive med hist
• dental hist and treatment review
• subjective evaluation of symptoms/complaints
• objective exam (IO EO hard tissue)
• radio assess
• clinical assess (vitality test)

Consider extraction when

• infectious process cannot be arrested by pulp therapy
• bony support cannot be regained
• inadequate tooth structure remains for a restoration
• excessive pathological root resorption exists

Vital Pulp therapies

• indirect pulp cap
  • preferable to pulpotomy when reversible pulpitis
  • complete caries removal not needed for success
  • restored with material that seals tooth from microleakage
• direct pulp cap
  • indicated in primary tooth with normal pulp following small mechanical or traumatic exposure
  • MTA/CaOH placed in contact with exposed pulp tissue
  • not recommended, pulpotomy better
• pulpotomy
  • indicated when caries removal results in pulp exposure or after traumatic pulp exposure, must be reversible or normal pulp
  • coronal tissue amputated, radicular tissue is vital without suppuration, purulence, necrosis or excessive haemorrhage
  • MTA/ZOE fill then SSC
    

Pulpectomy in deciduous dentition

• indications
  • evidence of pulpal necrosis
  • tooth is restorable
  • prolonged history of spontaneous pain
  • buccal or EO swelling and increased mobility
  • radiolucent furcation involvement or PA RL on radiograph
  • persistent bleeding during pulpotomy (hyperaemic pulp) or suppuration or purulence (pulp necrosis)
• contraindications
  • relevant med hist (immunodeficiency)
  • tooth unrestorable
  • periradicular involvement extending to permanent tooth bud
  • pathologic resorption of >1/3 root
  • excessive internal root resorption
  • mechanical or carious perforation of floor of pulp chamber
  • presence of a dentigerous cyst

Clinical procedure

• preop radiograph, estimate WL
• LA, rubber dam
• remove caries
• gain access to pulp chamber
• remove coronal pulp
• identify orifices or root canals
• instrument canals
• irrigate
• dry canals (temporise if 2 stage)
• obturate canals (GP contraindicated as doesn't resorb)
• resotre coronal cavity (IRM -> GIC)
• postop radio
• SSC
• review every 6-12mo

FIlling materials for deciduous pulpectomy

• property should resorb at rate similar to that or roots of treated deciduous teeth
• antibacterial effects are desirable
• combination CaOH with iodoform
  • endoflax or vitapex
  • greatest success, best option for deciduous root filling
  • vitapex may wash out from some canals, but teeth still remain asymptomatic most times
  • non significant antibacterial effect
• iodoform
  • KRI paste
  • moderate antibacterial effect
  • good success rate
• non reinforced ZOE
  • tends to resorb slower than primary roots
  • associated with over retention of deciduous tooth
  • possible ectopic eruption of succedaneous tooth
• pure CaOH
  • contradictory results

Deciduous pulpectomy prognosis

• success rate 75-95%
• when preservation of tooth not deemed essential, clinicians may advise considering exo