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PULPOTOMIES FOR PRIMARY TEETH

I. Pulpal Anatomy and Physiology in Primary Teeth

Dental and Pulpal Anatomy
 The enamel and dentine of primary teeth are thinner than in permanent teeth  The pulps of primary teeth are relatively larger than those of permanent teeth  The pulp chambers of primary mandibular molars are relatively larger than those of maxillary molars  There are pulp horns under each primary tooth cusp, and these can be quite prominent

Dental and Pulpal Anatomy cont.
• The mesial pulp horns in primary molars are usually closer to the occlusal surface than the distal pulp horns, and therefore easier to expose • The outline of the pulp chamber roof follows that of the occlusal surface • Primary molars have a thin pulpal floor which may have accessory canals that communicate with the inter-radicular area •

Dental and Pulpal Anatomy cont.
 The root canals of primary molars can be narrow, ribbon-like and tortuous, and with deposition of secondary dentine, multiple canals may form with many ramifications  Maxillary molars usually have 4 canals (2 in the mesio-buccal root)  Mandibular molars usually have 3 canals (2 in the mesial root)

and 12% water • The inorganic portion is mainly hydroxyapatite crystals • The organic component is mainly collagen and proteoglycans .Dentine • An avascular and mineralised connective tissue • Has a tubular structure connecting the enamel and the pulp • About 70% inorganic material. 18% organic material.

The basic structural entities of dentine are: (1) the odontoblast with the odontoblast process. (4) the peritubular dentine. . (3) the peri-odontoblastic space.Dentine cont. (2) the dentinal tubule. and (5) the intertubular dentine.

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• The peri-odontoblastic space lies between the wall of the tubule and the odontoblast process. • They have long odontoblast processes which are located in the dentinal tubules in the dentine.Odontoblasts • The odontoblasts are specialised cells lining the pulp. .

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. and between odontoblasts and the nerve-like fibroblasts in the pulp. particularly peripherally. • Intercellular junctions are found between odontoblasts. and may be important in the transmission of nerve impulses. • The peri-odontoblastic space contains tissue fluid and a few organic constituents.Odontoblasts cont. • The odontoblast processes and tubules may branch.

• The number and course of the tubules in the secondary dentine become more irregular due to progressive crowding as the odontoblasts move towards the pulp. . This slowly reduces the size of the pulp chamber with age.Primary and Secondary Dentine • Primary dentine is formed during tooth development. • Secondary dentine is formed after the crown of the tooth is fully formed.

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peritubular dentine is laid down with increasing age and may eventually completely obliterate the tubules.Secondary Dentine cont. . • Under areas of external irritation such as attrition. caries and restorations increased depositions of secondary dentine with a particularly irregular structure are found. • Also.

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The Pulp • The dentine and the pulp constitute the major part of the tooth. . • There is an intimate relationship between the dentine and pulp both developmentally and functionally. • The pulp is surrounded by dentine except at the apical foramen where it communicates with the periodontal tissues.

• The pulp is a loose connective tissue made up of nerves. • It is about 25% organic material and 75% water by weight. the predentine is lined by a layer of specialised pulp cells. the odontoblasts. .flattened cells with an oval nucleus. for example. • The most common cells in the pulp are fibroblasts . • Other cells are also found.The Pulp cont. blood vessels and connective tissue.

The Pulp cont. • The arterioles end in a dense capillary network especially in the odontoblastic and subodontoblastic region. • Because the pulp is rich in blood vessels local trauma or irritation can result in a hyperaemic reaction. • Small blood vessels (arterioles and venules) enter and leave the pulp through the apical foramen. . and through any accessory root canals.

caries.The Pulp cont. • With increasing age the pulp changes from a cell-rich and fibre-poor young tissue. or restorative procedures. • The functional processes within the pulp also decrease with age. • These are sometimes seen on radiographs. to a more cell-poor and fibre-rich old tissue. • These changes are accentuated if the teeth are subjected to external irritation eg attrition. . • Pulp stones are islands of mineralised material in the pulp that are more common in pathologically altered teeth.

CLINICAL PULP TREATMENT FOR PRIMARY TEETH .

Why pulp therapy for primary teeth? • Important to maintain primary teeth for the development of dentition (maintain arch length) • Prevent infection and pain • Can help to nurture a positive attitude about oral health in children • Can preserve primary tooth where permanent successor is missing • Can helps maintain masticatory function • Preserves aesthetics • Sends message that “primary teeth are important!” .

Space Loss Due to Premature Extraction of Primary Molar .

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and retain the tooth • Success depends on type of wound dressing. pulpal diagnosis at time of treatment. amputation technique and treatment of wound surface .What is a pulpotomy? • Vital amputation of the (inflamed or infected) coronal pulp • Wound surfaces at orifaces of root canals are then treated in order to preserve vitality of radicular pulp.

Large carious pulp exposure .

PULPOTOMY .

Properties of an Ideal Pulpotomy Material • Bactericidal • Harmless to the pulp. surrounding tissues and underlying tooth germ • Promote healing • Not interfere with the physiological process of root resorption .

glutaraldehyde. ferric sulphate – Also . plain Ca(OH)2 – Devitalizing medicaments – aim to maintain primary tooth irrespective of pulpal condition eg formocresol.Types of Medicament Two main groups: – Calcium hydroxide preparations – stimulate a hard tissue barrier. promote healing. Ledermix.MTA . eg Vitapex.

(1) Calcium Hydroxide • Strongly alkaline (pH about 12) • Irritation causes initial necrosis adjacent to vital pulp tissue • Pulp responds with an inflammatory reaction • Later repair process starts with proliferation of cells and formation of new collagen • Odontoblasts differentiate and form a hard dentine-like tissue (but this is NOT a tight seal) • Only successful for healthy pulps and those with partial chronic reversible pulpitis • Success rates only about 60% in some studies .

can be very successful . or the presence of a blood clot over the pulp wound surface • If placed in the right situation directly onto the pulp wound.Complications of use of Ca(OH)2 • Internal dentine resorption • Often due to chronic inflammation of the residual pulp.

(2) Formocresol • Use a 1/5 dilution of the original Buckley’s solution (1930s): – Tricresol 35% – Formaldehyde 19% (a histological fixing agent) – Glycerol 15% – Water 31% • Bactericidal • Devitalizing .

degree of penetration is time and dose-dependent • May end up with chronic inflammation or even partial necrosis of residual pulp .Formocresol (cont) • Aim to create a chemically altered zone at the pulp-medicament interface – leaving the deeper untreated pulp tissue vital and un-inflamed • Diffuses into the pulp tissue .

Formocresol cont. mutagenic potential – but no data to support toxic effects from pulpotomies in humans . • Higher success rate than calcium hydroxide • Systemic absorption of FC shown in animal studies where large nos of teeth had pulpotomies with full strength FC • Suggested FC may have immunogenic. toxic.

radiographic success >60% in most studies .Complications of Use of Formocresol • Can get chronic inflammation or necrosis of residual pulp – but clinical and radiological problems may not occur for several years • One early study reported a few cases of hypoplasia of underlying permanent tooth • Success rates vary – clinical success rates over 90%.

(3) Ferric Sulphate (15.5%) • Used in dentistry to control gingival bleeding eg before crown impression taking (called Astringident) • Forms a ferric ion-protein complex on contact with blood  seals vessels • Clinical studies show similar clinical success to formocresol • Little chance of success if pulp in roots inflamed .

(4) Glutaraldehyde • • • • Better fixative cf FC Larger molecules  less penetration Toxic properties eg allergies. eye irritation Seldom used .

Other Methods • Electrosurgery (may be in combination with FC) • Lasers • MTA .

Radiographs • Must have preoperative radiograph which shows the furcation area (or preferably the whole tooth) – PA is best • Should also have a post-op radiograph • Follow up radiograph at 6 months and then annually .

PULPOTOMY TECHNIQUE .

6 or 8 round low speed burs and/or large sharp excavator (do NOT cut through furcation!) Arrest bleeding from root orifaces with cotton pellets Place damp cotton pellet with FC or FS in pulp chamber for 1-5 min Mix ZOE or IRM (thick mix) and fill pulp chamber Restore tooth eg with ss crown • • .Steps • • • • • • • Pre-op radiograph Isolate tooth Remove all caries Remove roof of pulp chamber with high speed bur Remove pulp with no.

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Note: • Studies show that if the marginal ridge is broken down. there is often inflammation of the pulp horn • Direct pulp capping has a poor success rate in primary teeth – pulpotomy better • In Cambodia there are many abscessed teeth following placement of deep restorations because pulp already inflamed • Teeth with pulpotomies tend to exfoliate early .

INDICATIONS FOR PULPOTOMY • Large carious lesion with substantial loss of marginal ridge • Restorable tooth • No radicular pulpitis: – No spontaneous / persistent / severe pain – No persistent bleeding (or pus) from radicular amputation site • • • • • No abscess or fistula or swelling or mobility >1/2 of root remaining No periapical/furcal bone loss No internal resorption of crown or root Bleeding disorders .

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CONTRA-INDICATIONS FOR PULPOTOMY • • • • • • • Unrestorable tooth Abscess/fistula/swelling/mobility Periapical / furcal radiolucency <2/3 of root remaining Internal resorption Continued bleeding after application of FC Medical conditions: – Heart problems requiring Ab cover – immunocompromised .

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Suitable Case (if pulp healthy) .

Unsuitable Case – Why? .

ABSCESS .

Unsuitable case – Why? .

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Pulpotomized Teeth are Best Restored with SS Crowns .

internal resorption. or abscess indicate failure  extraction or pulpectomy .FOLLOW UP • Review clinically and radiographically at 6 mo and then annually • PA or PBWs which show furcation area • Appearance of a radiolucency.

Complications/Failures .

some dentists add a drop of FC the ZOE/IRM mix .Notes • If health of pulp doubtful.