PEDODONTICS LECTURE TWO 23/1/2017

Clinical pulpal diagnosis in young permanent teeth radiographic exaination.

1) Radiographs are necessary for:

1. A
ssessing the depth of caries lesions
2. M
orphology of the pulp chamber
3. D
egree of root development
4. H
eight of the pulp horns
5. I
ntegrity and depth of restorations
6. L
evel of bone support
7. P
resence of periradicular or periapical changes (PDL and resorptive changes)
8. C
alcified bridge formation if present

2) Radiographic interpretation of young permanent teeth is difficult

1. L
arge and open apex
2. R
adiolucent apical papilla which gives an impression of giving an impression of
periapical radiolucency
3) ?

4) Cone Beam Computer Tomography (CBCT)

 I
t is difficult to determine the extent of apical closure in a regular radiograph
showing only the mesio-distal plane
 R
oot canals of permanent teeth are wider in the bucco-lingual plan than the mesio-
distal
 C
BCT is a technique that produces undistorted three-dimensional digital imaging of
the teeth and their surrounding tissues at reduced cost and less radiation for the
patient than traditional CT scans
 T
he American Association of Endodontics (AAE) and the American Academy of
Oral and Maxillofacial Radiology (AAOM) states that use of CBCT is justified
where the benefits to the patient outweigh the potential risks of exposure to x-rays,
especially in the case of children or young adults.

5) Figure 8.1

6) Clinical pulpal diagnosis in young permanent teeth direct pulpal evaluation

 I
n some instances, during the clinical ttt, a final diagnosis can only be reduced by
direct visualization of the pulpal tissue
1. P
ulp tissue appearance
2. C
olor and amount of bleeding
 B
ased on these observations, the treatment plan may be confirmed or changed

7) Table 3.2 - Pulpal diagnosis for deep caries

8) Vital pulp therapy for young permanent teeth without pulp exposure: mature and
immature - protective liner
Protective liner definition:
 I
t’s a thinly-applied liquid
 P
laced on the pulpal surface of deep cavity preparation
 C
overing exposed dentin tubules
 A
cts as a protective barrier between the restorative material or cement and the pulp
Liners:
1. C
alcium hydroxide
2. D
entin bonding agent
3. G
lass ionomer cement
*Liner must be followed by a well-sealed restoration to minimize bacterial leakage
from the restoration dentin interface

9) Methods of caries excavation:

 C
omplete excavation
 S
tepwise excavation
 P
artial excavation
 N
o excavation

10) Vital pulp therapy for young permanent teeth without pulp exposure - methods
of caries excavation:

Complete excavation:
 T
raditional operative dentistry approach to deep caries treatment
 C
omplete excavation of all the infected and affected dentin
 S
low-speed rotary burs and hard instrument are used

Rate of pulp exposure:

 A
pulp exposure can occur when complete excavation of deep caries is employed
 P
artial caries removal reduce the incident of an exposure by 77% compared to
complete excavation
 T
he amount of remaining dentin under a restoration has been shown to be the most
critical factor in determining the future health of the pulp

Complete excavation and direct pulp capping for permanent teeth:

 D
irect pulp capping after pulp exposures resulting from excavating deep caries has
been shown to have low success in permanent teeth
 C
arious exposure has a 33% pulp capping success compared to 92.2% success for a
mechanical exposure

11) Stepwise caries excavation (SW):

 S
tepwise excavation is done over two visits

The first excavation:

 R
emove the superficial necrotic, infected dentine by completely excavating the
periphery of the lesion
 R
emove the superficial necrotic, infected dentine by completely excavating the
periphery of the lesion (Dentin-enamel junction (DEJ))
 T
he excavation does not excavate caries near the pulp to avoid a pulp exposure
 L
eaving soft, moist, discolored dentin on the pulp floor
 t
he dentin is then covered with calcium hydroxide and a glass ionomer temporary
filling
 S
W is intended to allow remineralization of the affected dentin and formation of a
more tertiary dentin

The objective is to change the cariogenic environment through:

1. D
ecrease the number of bacteria
2. C
lose the remaining caries from the biofilm of the oral cavity
3. S
low or arrest the caries development

12) The second excavation:

 T
he carious lesion is re-entered in 8-12 weeks
 F
inal complete excavation is done leaving only central yellowish or grayish hard
dentin in the pulpal floor
 A
well-sealed final restoration is placed

13) No caries excavation:

 I
ts has been reported in primary teeth
 I
t involves no drilling or excavation of any caries
 A
stainless crown to seal the caries and stop its progress is used
 T
he technique is termed the Hall technique (named after Norna Hall, a Scottish
dentist)
 I
t presumes that sealing the infected and affected dentin from micro-leakage will
arrest the caries
 W
hether the Hall technique is indicated for use in teeth with deep dental caries is yet
unknown

Permanent teeth:
 I
n a 10-year prospective study, frank carious lesions in permanent teeth that
extended Radiographically into less than half the dentin were sealed
 N
o caries excavation was done and the caries was sealed in place with a self-setting
occlusal sealent
 I
t showed arrest of the lesions over 10 years if the occlusal sealant stayed intact

14) ?

15) Carisoly:
 A
chemo-mechanical approach of caries removal
 I
t depend on dissolution rather than drilling
 T
his method involves a use of a gel and a specially designed hand instruments
 T
he gel comprimises three amino acids (glutamic acid, leucine, and lysine) and low
concentration of sodium hypochlorite
 W
ith carisoly sound and carious dentine are clinically separated and only carious
dentin is removed resulting in a more conservative preparation
 N
o pulpal or tissue irritation
 W
e usually use adhesive restorations
 C
arisoly contributes to patient comfort as it has been said to be painless, requiring
less drilling and local anesthesia
 T
he main drawback in this technique is the time needed to complete the procedure

END OF LECTURE
REEM SALIH