Pulp Therapy 5thyear by Marwanalamri-1

Pedodontics.
Pulp Therapy for Primary and Young Permanent Teeth
Introduction
Diagnostic
Vital pulp therapy.
- Pulp Capping
a. Indirect pulp capping
b. Direct pulp capping
-pulpotomy
(A) Formocresol pulpotomy: (1) Single visit technique:
(2) Two visit technique
(B) Calcium hydroxide pulpotomy (Apexogenesis):
Mortal pulpatomy
Partial pulpotomy - Cvek technique (pulp curettage):
Non-Vital pulp therapy Technique

Partial pulpectomy (single visit technique):
B) Complete pulpectomy (two visit technique):
Apexification:
Introduction
Pulp therapy for the primary dentition includes a variety of treatment options,
depending on the vitality of the pulp. Conservative treatment is performed when
vitally pulp remains because recovery is possible once the irritation has been
removed. Pulpectomy is indicated in teeth showing evidence of chronic, irreversible
inflammation or necrosis in the radicular pulp.
Pulp exposure is caused most commonly by caries but may also occur during cavity
preparation or by fracture of the crown. Pulp exposures caused by caries is invariably
accompanied by infection of the pulp, and it occur more frequently in primary than in
permanent teeth because primary teeth have relatively large pulp chambers, more
prominent pulp horns and thinner enamel and dentine.
Pulp therapy 5th year pediatric dentistry . prepared by Dr. Marwan S. S. Alamry
The infected pulp becomes inflamed and necrosis may result. If infection spreads to
the alveolar bone the developing permanent tooth may be affected.
The inflammation may remain sub-acute or chronic and give the patient little or no
pain but the process may become acute at any time. For these reasons, a primary
tooth with a pulp exposure should not be left untreated.
Primary molars require pulp treatment much more commonly than primary anterior
teeth. The methods of treatment include pulp capping, pulpotomy and pulpectomy.
Diagnostic
In the diagnostic is very important to consider physical condition of the patient,
history of pain, clinical examination, and radiographic examination.
1. Physical condition of the patient
The pulp therapy in the primary dentition is contraindicated in children with:
Congenital cardiac disease
Immunosuppressed patients
Children with nephritis, leukemia, tumors, cyclic neutropenia, uncontrolled diabetes.
2. History of pain.
The dentist should distinguish between two types of pain, provoked and spontaneous
pain.
Provoked pain is stimulated by heat, cold, sweets, air and chewing. When the
stimulus is removed the pain is reduced or disappears.
These signs often indicate that the pulp is vital and protected by a thin layer of
dentine and can be treated successfully with good prognosis. Many children complain
about food impaction from interproximal caries and such gingival discomfort should
not be confused with pain from pulpal origin.
Spontaneous pain usually wakes a child at night and may not relieve by analgesics.
These signs usually indicate advanced, irreversible pulp damage or the beginning of
abscess formation. It is common to find that pain is reduced once an abscess has
formed and the infection has broken through the cortical plate.
Question to answers:
PAIN: An accurate history must be obtained of the type of pain, duration, frequency,
location, spread, aggregating and relieving factors.
Mode: is the onset spontaneous or provoked?
Periodicity: do symptoms have temporal pattern or are they sporadic or occasional?
Early pulpitis- symptoms seen in evening or after meal.
Frequency: have the symptoms persisted since they began/ have they been
intermittent?
Duration: how long do symptoms last when they occur?
Quality of pain:
Dull, aching - pain of bony origin.
Throbbing, pounding, pulsing - pain of vascular origin.
Sharp, recurrant, stabbing - pathosis of nerve root complexes, irreversible pulpitis.
Postural change: pain accentuates by bending over,
Hormonal: menstrual tooth ache due to increase in body fluid retention. Teeth may
ache and may become tender on percussion, symptoms disappear when cycle ends
Clinical Examination.
A careful intraoral examination is of extreme importance in detecting the presence of
a pulpally involved tooth.
a. Mobility: Pathological mobility must be distinguished from normal mobility in
primary teeth near exfoliation.
Abnormal tooth mobility is a clinical sign that may indicate a severely diseased pulp
or involvement of periodontal ligaments.
b. Sensibility to percussion: Percussion should start with a very gentle and careful tap
by the tip of the finger to prevent exposing the child to uncomfortable stimuli.
If the tooth is sensitive to percussion this indicates apical or pulpal inflammation or
both.
c. Swelling : Swelling usually indicates a necrotic pulp with spread of inflammation
into the soft tissues. Presence of swelling, sinus, draining fistula or chronic abscess
associated with a deep carious lesion is a sign of an irreversibly diseased pulp (non
vital pulp)
d. Size of exposure and amount of pulpal bleeding: Size of exposure, appearance of
the pulp and amount of bleeding are the most valuable observation in diagnosing the
condition of the primary pulp.
The most favorable condition for vital pulp therapy is the small pin point exposure
surrounded by sound dentine. If the exposure is large and associated with watery
exudates or pus the tooth is not suitable for vital pulp therapy.
Radiographic interpretation
The clinical examination should be followed by a high quality periapical and bit wing
radiograph to examine periapical area and supporting bone. Pulp exposure can not
be accurately from an x- ray film.
Radiogrraphs are valuable for determining periapical and interradicular changes such
as thickening or widening of periodontal membrane space, rarefaction in supporting
bone, presence of calcified masses within the pulp chamber and root canals, and
periapical and interradicular radiolucencies of bone.
Vitality tests
Vitaly test are of a little clinical benefit in young children because false positives and
negatives are too often present, especially in the anxious or uncooperative child, but
it should be taken into consideration. It gives an indication of whether the pulp is
vital but it does give a reliable evidence about the extent of the pulp disease.
Pulp vitally tests may be used either thermal or electrical.
Thermal pulp vitality test.

When application hot or cold stimulus the pain should disappear after removal the
stimulus. If the pain persists, this indicate pulpitis. If the child does not feel any pain
this is an indication of non vital pulp.
Electric pulp tester.
If the pulp of the affected tooth responds at lower reading than normal this denotes
hyperemia or pulpitis. If it responds at a higher reading than normal this is an
indication of pulp degeneration.
Vital pulp therapy.

- Pulp capping
The aim of pulp capping is to maintain pulp vitally by placing a suitable dressing
either directly on the exposed pulp (direct pulp capping) or on a thin residual layer of
slightly soft dentine (indirect pulp capping).
Zinc oxide-eugenol is a germicidal agent which kills bacteria present in carious lesions
and prevent progression of caries toward the pulp. This gives the chance to the pulp
for healing and regeneration. Many authors recommend Calcium hydroxide for
primary teeth.
Calcium hydroxide is usually used for pulp capping because it stimulates the
formation of secondary dentine more effectively than do other materials. Clinical
studies have shown that the technique is successful when strict criteria are applied in
selecting cases for treatment.
Indirect pulp capping
Indirect pulp treatment is a procedure performed in a tooth with a deep carious
lesion approximating the pulp but without signs or symptoms of pulp degeneration.
The caries surrounding the pulp is left in place to avoid pulp exposure and is covered
with a bio-compatible material.
A radiopaque liner such as a dentin bonding agent, resin modified glass ionomer,
calcium hydroxide, zinc oxide/eugenol or glass ionomer cement is placed over the
remaining carious dentin to stimulate healing and repair. If calcium hydroxide is used,
a glass ionomer or reinforced zinc oxide/eugenol material should be placed over it to
provide a seal against micro leakage since calcium hydroxide has a high solubility,
poor seal, and low compressive strength. The use of glass ionomer cements or
reinforced zinc oxide/eugenol restorative materials has the additional advantage of
inhibitory activity against cariogenic bacteria. The tooth then is restored with a
material that seals the tooth from microleakage. Interim therapeutic restorations
(ITR) with glass ionomers may be used for caries control in teeth with carious lesions
that exhibit signs of reversible pulpitis. The ITR can be removed once the pulp s
vitality is determined and, if the pulp is vital, an indirect pulp cap can be performed.
Current literature indicates that there is no conclusive evidence that it is necessary to
reenter the tooth to remove the residual caries. As long as the tooth remains sealed
from bacterial contamination, the prognosis is good for caries to arrest and
reparative dentin to form to protect the pulp. Indirect pulp capping has been shown
to have a higher success rate than pulpotomy in long term studies. It also allows for a
normal exfoliation time. Therefore, indirect pulp treatment is preferable to a
pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis
- Contraindications:
1. Spontaneous pain
2. Inflammation
3. Tooth mobility
4. Periapical and interradicular changes
Theory of indirect pulp capping
Indirect pulp therapy is a technique for avoiding pulp exposure in the treatment of
teeth with deep carious lesions in which there exists no clinical evidence of pulpal
degeneration or periapical disease. The procedure allows the tooth to use the natural
protective mechanisms of the pulp against caries. It is based on the theory that a
zone of affected, demineralized dentin exist between the outer infected layer of
dentin and the pulp. When the infected dentin is removed, the affected dentin can
remineralize and the odontoblasts form reparative dentin, thus avoiding pulp
exposure. Kopel has identified three distinct layers in active caries:1. Necrotic, soft
dentin not painful to stimulation and grossly infected with bacteria. 2. Firm but
softened dentin, painful to stimulation but containing few bacteria. 3. Slightly
discolored, hard, sound dentin containing few bacteria and painful to stimulation.
In indirect pulp therapy the outer layer of carious dentin are removed. Thus most of
the bacteria are eliminated from the lesion. When the lesion is sealed, the substrate
on which the bacteria act to produce acid is also removed. Exposure of the pulp
occurs when the carious process advances faster than the reparative mechanism of
the pulp. Care must also be taken in removing the caries to avoid exposure of the
pulp. With the arrest of caries process, the reparative mechanism is able to lay down
additional dentin and avoid a pulp exposure. If the preliminary caries removal is
successful, the inflammation will be resolved and deposition of reparative dentin
beneath the caries will allow subsequent eradication of the remaining caries without
pulpal exposure. The rate of reparative dentin deposition has been shown to average
1.4um/day after cavity preparation in dentin of human teeth. The rate of reparative
dentin formation decreases markedly after 48days. Dentin is laid down fastest during
the first month after IPC and the rate diminishes steadily with time.
If the initial treatment is successful, when the tooth reentered the caries appears to
be arrested. The color changes from deep red rose to light grey to light brown. The
texture changes from spongy and wet to hard, and the caries appears dehydrated.
The goal is to promote pulpal healing by removing the majority of the infected
bacteria and sealing the lesion, which stimulates sclerosis of dentin and reparative
dentin formation. As the procedure was originally practiced, after a minimum of 6
weeks the zinc oxide and eugenol, calcium hydroxide, and remaining carious dentin
are removed. It was intended that the second instrumentation of the tooth would
confirm the intended goals and would be followed by placement of a permanent
restoration. For the experienced clinician using good case selection, however it may
be preferable to avoid second instrumentation (and the potential risk of pulpal
exposure ).
Periodic follow up of the tooths history along with pulp vitality testing and
radiographic assessment is necessary. Indirect pulp capping is the excellent and
conservative treatment option for some deep carious lesions in permanent teeth
(especially if it avoids complete root canal treatment). It should be emphasized that
the indirect pulp cap procedure is intended to avoid direct caries exposure.
- TECHNIQUE OF INDIRECT PULP CAPPING
First appointment Use local anesthesia and isolation with rubber dam.
↓
Establish cavity outline with high speed hand piece.
↓
Remove the superficial debris and majority of the soft necrotic dentin with slow
speed hand piece using large round bur.
↓
Stop the excavation as soon as the firm resistance of sound dentin is felt.
↓
Periapical carious dentin is removed with a sharp spoon excavator.
↓
Cavity flushed with saline and dried with cotton pellet.
↓
Site is covered with calcium hydroxide.
↓
Remainder cavity is filled with reinforced ZOE cement.
Second appointment (6-8 weeks later) Between the appointment history must be
negative and temporary restoration should be intact.
↓
Take a bitewing radiograph and observe for sclerotic dentin.
↓
Carefully remove all temporary filling material.
↓
Previous remaining carious dentin will have become dried out, flaky and easily
removed.
↓
The area around the potential exposure will appear whitish and may be soft; which is
predentin. Do not disturb this area.
↓
The cavity preparation is washed out and dried gently.
↓
Cover the entire floor with calcium hydroxide.
↓
Base is built up with reinforced ZOE cement or GIC.
↓
Final restoration is then placed
Fig: Indirect pulp therapy. A, A primary or permanent tooth with deep caries. B, The
gross caries has been removed and the cavity sealed with durable biocompatible
cement or restorative material. C, Six to 8 weeks later the cavity is reopened and the
remaining caries excavated. A sound dentin barrier protects the pulp, and the tooth
is ready for final restoration.
b.Direct pulp capping

The procedure in which the small exposure of the pulp, encountered during cavity
preparation or following a traumatic injury or due to caries, with a sound surrounding
dentin, is dressed with an appropriate biocompatible radiopaque base in contact
with the exposed pup tissue prior to placing a restoration is termed as direct pulp
capping. - Indications:
They should be limited to traumatic exposure (during cavity preparation)
Small pin point exposure surrounded by sound dentine.
Recent exposure.
Vital pulp free from infections.
No bleeding at the exposure site or an amount that would be considered normal.
Normal radiographic findings.
CONTRAINDICATIONS
1. Large pulp exposures. 2. Presence of caries surrounding the exposure site. 3.
Excessive bleeding indicates hyperemia or pulpal inflammation. 4. Pain at night. 5.
Spontaneous pain. 6. Tooth mobility. 7. Thickening of periodontal membrane. 8.
Intraradicular radiolucency. 9. Purulent or serous exudates. 10. Swelling. 11. Fistula.
12. Root resorption. 13. Pulpal calcification
- Technique:
Rubber dam provides only means of working in a sterile environment, so it has to be
used.
↓
Once an exposure is encountered, further manipulation of pulp is avoided.
↓
Cavity should be irrigated with saline, chloramines T or distilled water.
↓
Hemorrhage is arrested with light pressure from sterile cotton pellets.
↓
Place the pulp capping material, on the exposed pulp with application of minimal
pressure so as to avoid forcing the material into pulp chamber.
↓
Place temporary restoration.
↓
Final restoration is done after determining the success pulp of capping which is done
by determination of dentinal bridge, maintenance of pulp vitality, lack of pain and
minimal inflammatory response.
HISTOLOGICAL CHANGES AFTER PULP CAPPING
These were illustrated by Glass and Zander in 1949.
After 24 hours: Necrotic zone adjacent to ca (oh) 2 pastes is separated from
healthy pulp tissue by a deep staining basophilic layer.
After 7 days: Increase in cellular and fibroblastic activity.
After 14 days: Partly calcified fibrous tissue lined by odontoblastic cells is seen
below the calcium protienate zone; disappearance of necrotic zone.
After 28 days: Zone of new dentin
Pulpotomy. A pulpotomy is performed in a primary tooth with extensive caries but
without evidence of radicular pathology when caries removal results in a carious or
mechanical pulp exposure. The coronal pulp is amputated, and the remaining vital
radicular pulp tissue surface is treated with a long-term clinically-successful
medicament such as Buckleys Solution of formo-cresol or ferric sulfate. Several
studies have utilized sodium hypochlorite with comparable results to formocresol
and ferric sulfite. Calcium hydroxide has been used, but with less long term success.
MTA is a more recent material used for pulpotomies with a high rate of success.
Clinical trials show that MTA performs equal to or better than formocresol or ferric
sulfate and may be the preferred pulpotomy agent in the future.
The most effective long-term restoration has been shown to be a stainless steel
crown. However, if there is sufficient supporting enamel remaining, amalgam or
composite resin can provide a functional alternative when the primary tooth has a
life span of two years or less
INDICATION-:
1)Carious or mechanical exposure of vital primary teeth and young permanent
teeth,where inflammation is restricted to coronal pulp only.
2) No History of spontaneous pain.
3) Hemorrhage from exposure sites bright red and be controlled.
4)Absence of abscess or fistula.
5)No interradicular bone loss.
6)No interradicular radiolucency.
7)At least 2/3rd of root length still present to ensure reasonable functional life.
8) In young permanent tooth with vital exposed pulp and incompletely formed apices
CONTRAINDICATION 1. History of spontaneous pain 2. Swelling 3. Fistula 4.
Tenderness to percussion 5. Pathological mobility 6. External/internal root resorption
7. Periapical or interradicular radiolucency 8. Pulp calcifications 9. Pus or exudate
from exposures site 10. Uncontrolled bleeding from the amputated pulp stump 11.
Root resorption more than 1/3rd of root length 12. Large carious lesion with non-
restorable crown 13. Highly, viscous, sluggish hemorrhage from canal orifice, which is
uncontrollable 14. Medical contraindications like heart disease,
immunocompromised patient
Technique for Pulptomy of the Primary Teeth
Anesthetize the tooth and isolate with rubber dam. ↓
•Remove all caries using high-speed straight fissure bur without entering the pulp
chamber.
•Remove dentinal roof with a large diamond stone or slow speed round bur for
minimal trauma.
•Enlarge the exposed area and deroof the pulp chamber.
•Remove any ledges or overhanging enamel with slow speed round bur. Sharp
spoon excavators are used to scoop out coronal pulp and pulpal remnants.
Clean the pulp chamber with saline and remove all debris.
Place a cotton pellet over the pulp stumps to achieve hemostasis.
Using a cotton pellet apply diluted formocresol to the pulp for 4 min. ↓
•Place a small dry pellet over this to avoid contact of tissues with formocresol. ↓
•Remove cotton pellets and check for fixation,brownish discoloration of the pellet as
well as the pulp stump is an indicator of fixation. ↓
•Place ZOE cement in the pulp chamber ↓
•Recall after one week and restore with a permanent restoration if patient is
asymptomatic ↓
•Place a stainless steel crown
N.B: Pain during caries removal and instrumentation may be an indication of faulty
anesthetic technique. More often, however, it indicates pulpal hyperemia and
inflammation, which makes the tooth a poor risk for vital pulpotomy.
(A) Formocresol pulpotomy:
Indication: For the treatment of primary teeth with carious exposures.
(1) Single visit technique:
Indication: No sign and symptoms of extension of infection beyond coronal pulp to
root canals.
After control of bleeding, a cotton pellet dampened with Formocresol & squeezed in
a cotton roll or a piece of gauze to remove excess, is placed over the amputated pulp
for 4 minutes (it should be acknowledged that the 4-minute application time has
been determined somewhat arbitrarily). Because formocresol is caustic, care must be
taken to avoid contact with the gingival tissues.
Then, the pellets are removed and the pulp chamber is dried with new pellets. &
check that bleeding has stopped .Continuous bleeding means the inflammation of
radicular pulp thus shift to the 2- visit technique Pulpotomy or partial pulpectomy.
When the bleeding has stopped, the radicular pulp stump should appear dark brown
or even black as a result of fixation caused by the drug.
The pulp chamber is filled with A thick paste of hard-setting zinc oxide eugenol paste,
then Zinc phosphate cement is placed and the tooth is restored with stainless steel
crown. Some dentists prefer to make the pulp-capping material by mixing the zinc
oxide powder with equal parts of eugenol and formocresol. There are no proved
contraindications to adding formocresol to the mixture; however, neither are there
any proven benefits.
(2) Two visit technique
Indications:
The patient is too uncooperative to allow completion in one visit.
For vital primary teeth in which inflammation has extended to the radicular
filaments. Mortal pulpatomy or Partial pulpectomy is an alternative treatment.
Technique:
In the two visits Formocresol technique the coronal pulp is removed as previously
described.
A cotton pellet dampened with formocresol is sealed within the coronal pulp
chamber between appointments and cover with temporary dressing.
The second visit should occur one week after the first.
At the second, visit formocrosol is reapplied for 5 minutes, zinc oxide eugenol alone
or mixed with Formocresol is placed and a stainless steel crown is performed.
Two visit devitalization pulpotomy:
It is two stage procedures involving the use of paraformaldehyde (or other formulas)
to fix the entire coronal & radicular pulp tissue.
The medicament used has a devitalizing, mummifying, & bactericidal action.
Technique:
First appointment :-
Same as formocresol pulpotomy but place the paraformaldehyde paste in cotton
pellete over the exposure & seal the tooth for 1 to 2 weeks.
Formaldehyde gas liberates from the paraformaldehyde permeates through the
coronal and radicular pulp, fixing the tissue.
Second appointment :-
pulpotomy is carried out ( as usual)with the help of local anaesthesia
Types of formulas:
Cysi's Triopast (1929) Easlick's Paraformaldehyde past Paraform

(1955) (1970)
Tricresol 10 Paraformaldehyde 1.00 g Paraform

ml
Cresol 20 Procaine base o.o3 g Lignocain

ml
Glycerin 4 Powdered asbestos 0.50 g Propylen

ml
Paraformaldehyde 20 Petrolum jelly 125.00 Carbowa

g g
Zinc Oxide 60 Carmine To Carmine

g color
(B) Calcium hydroxide pulpotomy (Apexogenesis):

Indications:
Vital permanent teeth with immature root development.
Permanent teeth with exposed vital pulp, when there is a pathological change in the
pulp at the exposure site.
Permanent tooth with a pulp exposure resulting from crown fracture when the
trauma has also produced a root fracture of the same tooth.
Contraindication:
Inflamed radicular pulp (continuous hemorrhage).
Internal or external root resorption.
Non vital pulp.
Technique:
As previously described, the coronal pulp is excised and the bleeding is controlled.
A creamy paste composed of pure calcium hydroxide powder sterile saline solution is
applied without pressure to the amputated pulp stumps .The Ca (OH) 2 destroys any
remaining microorganism & promotes calcific bridge.
A layer of zinc oxide eugenol is placed over the calcium hydroxide to provide an
adequate seal.
Then, a layer of zinc phosphate-cement and the permanent restoration. After 1 year,
a tooth that has been treated successfully should have a normal periodontal ligament
and lamina dura, radiographic evidence of a calcific bridge formation at pulp stumps
and continued root growth are signs of treatment success.
Calcium hydroxide pulpatomy is considered as the first stage for treatment. The
second stage of treatment is conventional canal filling, once the apices have been
closed. This is because there are linear calcifications along the length of the root
canal after formation of calcific bridge. This will progress until the canal completely
appear calcified radiographically. Once this happened it is difficult to negotiate the
canal with instrument or EDTA, and choice of treatment (due to pulp remnants
become non vital and end with periapical pathosis) is apical surgery or extraction.
Mortal pulpatomy:
Definition: it is a compromising treatment done on non- vital primary teeth, where
pulpectomy is not practical.
Indication:
Acute pulpitis.
Irreversible pulpitis.
Infection extends to radicular portion of the pulp.
Pus at the exposure site or in coronal pulp chamber.
Technique:
Necrotic pulp is removed.
Infected radicular pulp is treated with strong antiseptic solution (Beechwood
creosote, Formocresol, Camphorated monochlorophenol CMCP, or KRI liquid) for 1-2
weeks.
Second visit: after 7-10 days, the tooth should be no longer mobile, tender for
percussion, or exhibiting a fistula. Antiseptic solution is replaced by antiseptic past
(Formocresol past or Zinc oxid past).
In this technique no attempt is made to debride the canals or to force material in to
them.
Action:
When degeneration is more the degree of success decrease. The treatment is depend
on the fixation and germicidal of formocresol.
Also by vapour action as well as wet contact.
Partial pulpotomy - Cvek technique (pulp curettage):
Definition: It is removal of coronal pulp tissue up to the level of healthy pulp. This
process is also known as partial pulpotomy (by Cvek; he state that; the time between
the accident and treatment is not critical so long as the superficially inflamed tissue is
removed prior to treatment).
Indications:
When zones of inflammation has extended more than 2 mm (in permanent teeth
only). in an apical direction but has not reached root pulp. E.g. A traumatic
exposure (a few days post injury in a large young pulp).
Technique:
Area is anaesthetized and isolated
A 2 mm. deep cavity is prepared into pulp using sterile diamond bur and copius water
coolent
Excess blood is removed by saline & small cotton pelletes
Calcium hydroxide is placed onto cavity
Sealed with ZOE reinforced IRM restoration.
N.B: It is rarely sucessful and hence has no clinical significant.
Reasons for failure:
Pulp is highly vascular so, even with slightest infection in any corner of pulp, the
whole of it gets infected very quickly.
It's practically impossible to remove one part of coronal pulp without disturbing the
other parts of it in pulp chamber.
Non-Vital pulp therapy Technique :( Primary teeth)
Pulpectomy Definition: It is the technique to gain an access to the root canals,
remove as much dead & infected material as possible & fill the root canals with a
suitable material to maintain the tooth in a non infected state.
The chemo-mechanical preparation of primary root canal with endodontic hand
instrument and irrigants is controversial.
Conventional root canal treatment RCT of primary teeth is very dangerous due to:
Apical canal opening of primary teeth are not always distinct. And there is possibility
for over instrumentation that may injure subjacent permanent tooth germ.
The root canal walls is very thin (especially of molars) to tolerate intracanal
instrumentation without perforation, in addition to presence of multiple accessory
canals.
The anatomy of these root is very complex (Root canal are flat, tortuous & multiple
branching) to be reliably cleaned with instrument and irrigants.
For all of that, great emphasis has been placed on the use of antimicrobial and tissue
fixative medicaments, especially in posterior teeth.
Indications:
Irreversible inflammation extending to radicular pulp.
Primary tooth with necrotic pulp.
Primary tooth with evidence of furcation pathology.
Presence of gingival abscess.
Pulpless primary teeth without permanent successors or with sinus tracts or in
hemophiliacs
Contraindication:
Teeth with non-restorable crowns.
Pathologic resorption of at least one third of the root with a fistulous sinus tract
Peri-radicular involvement extending to the permanent tooth bud.
Extensive pulp floor opening into the bifurcation.
Excessive internal resorption
Root canal filling materials for primary teeth:

A) Zinc Oxide (ZOE) paste:
Most commonly used root canal filling material for primary teeth.
Has bactericidal effect & decreases tooth pain.
Overfilling causes a mild foreign body reaction.
Rate of resorption is slower than that of the primary tooth root.
B) Ca (OH) 2 paste:
Generally not used in pulp treatment for primary teeth
C) VITAPEX (or Cryopaste or Metapex):
Ca (OH) 2 + Iodoform.
Nearly ideal material for filling primary root canals
Mixture is easily applied
Resorbs at a slightly faster rate than the primary tooth root
Has no toxic effect on permanent successors
Is radioopaque
D) IODOFORM (KRI) Paste:

Iodoform + ZOE
Resorbs rapidly and in synchrony with primary roots& has no undesirable effects on
succedaneous teeth
Material extruded into periapical tissue is rapidly replaced by normal tissue
Has superior antimicrobial action
Does not set into hard mass & can be removed if re-treatment is required.
Contains Iodoform 80.8%, Camphor 4.86%, Parachlorophenol 2.025%, and Menthol
1.215%.
E) GUTTA PERCHA:
Is not resorbable & so, is generally not used in pulp therapy for primary teeth
May be used only when succedaneous tooth bud is absent
F) WALKHOFF paste:
Is a mixture of parachlorophenol, camphor & menthol
G) MAISTO paste:
Contains zinc oxide 14 g, iodoform 42 g, thymol 2 g, chlorophenol, camphor 3cc, and
lanolin 0.50 g.
N.B: The filling material should be Iodoform, Oxypara, Vitapex or ZOE because these
materials are resorbed during the process of shedding & have a fixative & bactericidal
effects.
Ideal root canal obturating material for primary teeth:
Should not irritate the periapical tissues
Should not coagulate any organic remnants in canal
Should have a stable disinfecting power
Resorbe at a similar rate as the primary root
Should be radiopaque.
A) Partial pulpectomy (single visit technique):
Definition: It is the extirpation of normal or diseased pulp of tooth with an
incompletely formed root & an open apex.
Indications: when coronal pulp tissue and the tissue entering the pulp canals are vital
but show clinical evidence of hyperemia. Prolonged bleeding from radicular pulp
stump after amputation of coronal pulp tissue (indicating that the infection extend to
radicular pulp).
Contraindication:
The contents of the root canals show evidence of necrosis (suppuration).
In addition, there is radiographic evidence of a thickened periodontal ligament or of
radicular disease.
Technique: involve
Caries removal & access cavity preparation as in
Pulpotomy.
The necrotic pulp is removed from coronal pulp
chamber with hand instrument: Fine barbed broach; considerable hemorrhage will
occur at this point. A Hedstrom file is recommended in the removal of remnants of
the pulp tissue. In which the file removes tissue only as it is withdrawn and
penetrates readily with a minimum of resistance.
Care should be taken to avoid penetrating the apex of the tooth. Also
use of root canal instruments placed in a special handpiece for root
canal debridement is allowable but with extreme precaution.
Followed by copious irrigation using 3% hydrogen peroxide
followed by normal saline and then sodium hypochlorite
solution (0.5 1 %).
Limited canal instrumentation for only debridement using small files is done & this
accompanied by irrigation.
Dry the canal with sterile paper point.
Then , a cotton pellet moistened with compharated- parachlorophenol is placed into
the pulp stump for few minutes
Coat the canal walls with a thin mix of zinc oxide eugenol paste by the use of paper
point covered with that material or with Small Kerr files.
A thick mix of the treatment paste should be prepared, rolled into a point and carried
into the canal & condensed with root canal p1uggers into the canal. Another
approach is to inject the past in to the canals with pressure syringe.
An x-ray film may be necessary to allow evaluation of the success in filling the canals.
The tooth should be restored with stainless steel crown.
B) Complete pulpectomy (two visit technique):
Definition: It is the extirpation of normal or diseased pulp to or near the apical
foramen.
Indication:
If canals are accessible in case of necrotic pulp and if there is evidence of essentially
or normal supporting bone.
If infection spread beyond the furcal.
The periapical region involving periapicalor furcation pathosis.
Technique:
All the previous steps in partial pulpectomy from 1-6 are followed.
Then, the premedicated cotton pellet (camphorated monochlorophenol (CMCP) or a
1:5 concentration of Buckley's formocresol) remains in place until next appointment
after 7-10 days during this time, the medicament will fix
any remaining pulpal tissue remnants & killing any
remaining microorganisms.
Gentle canal debridement to remove the remaining
necrotic tissues as much as possible (using small files with aid of x-ray film for the
tooth to avoid over instrumentation) the apex of each root should be penetrated
slightly with the smallest file.
Followed by irrigation & drying canal with sterile pre-measured paper
points should be done.
The signs & symptoms of periapical or furcation pathosis resolve
by the time of second appointment. If not, another appointment
is planned for further filling & irrigation.
The canals are coated with ZOE, filled with thick mix of ZOE &
tooth restored with the conventional manner.
Obturation techniques:
Incremental fill technique.
Lentulo spiral technique.
Endodontic pressure syringe technique. With advantages of avoidance of air trap,
even amount of material is deposit and finally it allows the use of thick consistency.
N.B: If the second primary molar is lost before the eruption of the first permanent
molar, the dentist is confronted with the difficult problem of preventing the first
permanent molar from drifting mesially during its eruption. Special effort should be
made to treat and retain the second primary molar even if it has a necrotic pulp.
Similarly, longer than normal retention of a second primary molar may be desired
when the succedaneous second premolar is congenitally missing.
Summary of pulp therapy:

The dentist should think of the possible treatment options in a progressive manner
that takes into account both treatment conservatism (e.g., a pulpotomy is more
conservative than a partial pulpectomy) and post treatment problems).
The most conservative treatment possible may not always be the indicated
procedure after the dentist also weighs the risks of post treatment failure in a
particular case.
Treatment of young permanent tooth with extensive involvement of pulp:
1- Vital pulp:
Open apex: Calcium hydroxide pulpotomy then restoration with root canal treatment
RCT + restoration (Apexogenesis).
Closed apex: RCT + restoration.
2-Non-Vital pulp:
Open apex: Apexification then RCT.
Closed apex: RCT+ restoration.
Apexification:
Definition: it is the induction of root-end repair in non-vital permanent teeth with
open apices.
Indication:
Non vital pulp with open apex (blunderbuss canal).
Principles of treatment:
Detriment.
Filling the canal with calcium hydroxide.
Formation of a calcific barrier at the apex.
Conventional RCT is done when repair is complete.
Materials: Calcium hydroxide, Zinc oxide paste, antibiotic past, triclcium phosphate,
polyvinyl resin, or Collagen (calcium phosphate gel).
Technique:
Instrument is recommended with the same access opening of conventional RCT.
Pulp chamber is removed by barbed broach. Diagnostic aid like an x- ray will help in
assisting root length.
Head storm file is used with constant irrigation.
The powder should be mixed with saline or local anesthetic solution to the
consistency of creamy mixture.
The canal should not be filled with calcium hydroxide until sign and symptom are
absent.
Dry the canal and filed with calcium hydroxide within 2 mm of the radiographic apex.
Calcium hydroxide it self is not radio-opaque, it should be mixed with barium
sulphate powder in equal quantities, to facilitate post operative evaluation.
Follow-up:
6 Monthly evolutions of signs and symptoms. with aid of x-ray.
4 types of repair (by Frank 1966):
The apex is closed with no changes in root canal
A radiographically apparent calcific bridge forms just coronal to the apex.
The apex is closed with definite though minimum recession of the canal.
There is no radiographic evidence of apical closure.
N.B: once calcific repair has occurred calcium hydroxide paste is removed, the canal
is irrigated , and the final root filling placed.
N.B: Alternative to apexification is apical surgery (apecextomy) preceded by root
canal therapy but this is not recommended in children because of:
Surgical techniques should be avoided.
Thin apical wall, may make apical surgery difficult.
Already short root may be further reduced by apical surgery

Pulp Therapy 5thyear by Marwanalamri-1

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Pulp Therapy 5thyear by Marwanalamri-1

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Pedodontics.

Pulp Therapy for Primary and Young Permanent Teeth

Non-Vital pulp therapy Technique

Thermal pulp vitality test.

Vital pulp therapy.

Indirect pulp capping

b.Direct pulp capping

Cysi's Triopast (1929) Easlick's Paraformaldehyde past Paraform

Tricresol 10 Paraformaldehyde 1.00 g Paraform

Cresol 20 Procaine base o.o3 g Lignocain

Glycerin 4 Powdered asbestos 0.50 g Propylen

Paraformaldehyde 20 Petrolum jelly 125.00 Carbowa

Zinc Oxide 60 Carmine To Carmine

(B) Calcium hydroxide pulpotomy (Apexogenesis):

Reasons for failure:

Root canal filling materials for primary teeth:

D) IODOFORM (KRI) Paste:

Summary of pulp therapy:

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