Pulp Therapy in Pediatric Dentistry

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Pulp Therapy in Pediatric Dentistry

• Dr. Jeff Johnson
• Division of Pediatric Dentistry
• Department of Oral Health Science
• University of Kentucky

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Pulp Therapy in Pediatric Dentistry--A Review--

• Despite the modern advances in prevention of
  dental caries and an increased understanding of
  the importance of maintaining the natural
  dentition, many teeth are still lost
  prematurely.
• The primary objective of pulp treatment of an
  affected tooth is to maintain the integrity and
  health of oral tissues.

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Pulp Therapy in Pediatric Dentistry--A Review--

• Additional reasons to preserve the integrity of
  the primary dentition are to
• Reduce the likelihood of mesial drift and the
  resultant malocclusion.
• Aid in mastication.
• Preserve a pulpally involved primary tooth in the
  absence of a succedaneous tooth.
• Prevent possible speech problems.
• Maintain esthetics.
• Prevent aberrant tongue habits
• Prevent the psychological effects associated with
  early tooth loss.
• Maintain normal eruption time of the succedaneous
  teeth.

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Pulp Therapy in Pediatric Dentistry--A Review--

• Before attempting pulp therapy in the primary
  dentition, the clinician should be familiar with
  the basic differences between primary and
  permanent root canal anatomy.
• As a review, the pulp performs five major
  functions
• Induction
• Pulp participates in the induction and
  development of odontoblasts and dentin, which,
  when formed, induce enamel formation.
• Formation
• Odontoblasts form dentin. Dentin is formed
  continuously throughout the life of the tooth.
  Odontoblasts can also form a unique type of
  dentin in response to injury, such as occurs with
  caries, trauma, and restorative procedures.

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Pulp Therapy in Pediatric Dentistry--A Review--

• Pulp functions (continued)
• Nutrition
• Via dentinal tubules, pulp supplies nutrients
  that are essential for dentin formation and
  hydration.
• Defense
• Odontoblasts form dentin in response to injury,
  particularly when the original dentin thickness
  has been compromised by caries, wear, trauma, or
  restorative procedures. Pulp also has the
  ability to elicit an inflammatory and immunologic
  response in an attempt to neutralize or eliminate
  invasion of dentin by caries-causing
  microorganisms and their byproducts.

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Pulp Therapy in Pediatric Dentistry--A Review--

• Pulp functions (continued)
• Sensation
• Through the nervous system, pulp transmits
  sensations mediated through enamel or dentin to
  the higher nerve centers.
• The pulp of the primary tooth is histologically
  similar to that of a permanent tooth.
• Normal pulp has the following histological
  components
• Lymph vessels
• Blood vessels
• Nerve tissue
• Undifferentiated mesenchymal cells
• Fibroblasts
• Defense cells (neutrophils, lymphocytes, an
  macrophages)
• Odontoblasts
• Osteoclasts/Odontoclasts

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Pulp Therapy in Pediatric Dentistry--A Review--

• Characteristics of Pulp Tissue
• Most similar to connective tissue
• Tremendous healing potential
• Apical vascularity is important to healing
  potential
• Coronal tissue is more cellular
• Apical tissue is more fibrous
• Pulp becomes more fibrotic with age

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Pulp Therapy in Pediatric Dentistry--A Review--

• The healing potential of healthy pulp tissue is a
  function of
• The vascularity of the pulp.
• The absence of cariogenic and inflammatory
  bacteria.
• The cellular/structural integrity of the
  pulp/dentin/enamel complex.
• The absence of a chemical and/or thermal insult.

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Pulp Therapy in Pediatric Dentistry--A Review--

• The root canals of anterior primary teeth are
  relatively simple, have few irregularities, and
  are easily treated endodontically.
• The root canal systems found in posterior primary
  teeth, conversely, contain many ramifications and
  deltas between canals making thorough debridement
  quiet difficult.
• Generally, there is only one canal present in
  each root of the primary molars when the
  formation of the roots has been completed.
• The primary tooth root will begin to resorb as
  soon as the root length is completed.
• The resorption causes the position of the apical
  foramen to change continually.

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Pulp Therapy in Pediatric Dentistry--A Review--

• Simultaneously, secondary dentin is deposited
  within the root canal system.
• The deposition produces variations and
  alterations in the number and size of the root
  canals, as well a many small connecting branches
  between the facial and lingual aspects of the
  canals.
• Accessory canals, lateral canals, and apical
  ramifications of the pulp may be found in 10 to
  20 of primary molars.
• Primary teeth have characteristic ribbon-like
  radicular pulp.
• Primary molar roots are widely divergent and
  curved to allow for the development of the
  succedaneous tooth.

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Pulp Therapy in Pediatric Dentistry--A Review--

• The maxillary primary molars may have two to five
  canals, with the palatal root usually rounder and
  longer than the two facial roots.
• In the mesiofacial root, two canals occur in
  approximately 75 of the primary maxillary first
  molars and 85 to 95 of primary maxillary second
  molars.
• The primary mandibular first and second molars
  usually have three canals which generally
  correspond to the external root canal anatomy.
• Approximately 75 of the mesial roots in primary
  first molars contain two canals whereas in
  primary second molars, 85 of the mesial roots
  contain two canals.

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Pulp Therapy in Pediatric Dentistry--A Review--
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Pulp Therapy in Pediatric Dentistry--A Review--

• The thickness of enamel and dentin coronal to the
  pulp chamber is also thinner in a primary tooth.
• Since the distance from the occlusal surface and
  the floor of the pulp chamber is much shorter
  than in a permanent tooth, care must be taken
  when making an access opening into the pulp
  chamber to prevent perforation into the furcation
  area.

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Pulp Therapy in Pediatric Dentistry--Clinical
Assessment of Pulp Status--

• History of Pain
• Three important factors to consider
• Duration (how long does it hurt?)
• Frequency (how often does it hurt?)
• Location (where does it hurt?)
• Types of Pain and Pulp Status
• Irreversible Nonvital Therapy
• Spontaneous/Non-stimulated
• Nocturnal
• Constant

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Pulp Therapy in Pediatric Dentistry--Clinical
Assessment of Pulp Status--

• Types of Pain and Pulp Status (continued)
• Reversible Vital Therapy
• Thermal
• Chemical
• Intermittent
• Stimulated
• Extent of Lesion
• Location
• Color
• Mobility
• Differentiate between physiologic root resorption
  and pathologic root/bone loss

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Pulp Therapy in Pediatric Dentistry--Clinical
Assessment of Pulp Status--

• Soft Tissue Swelling/Lymphadenopathy
• Antibiotic treatment for dental infections in
  children
• Penicillin V 25 50 mg/kg QID/7 days
• Clindamycin 16 20 mg/kg QID/7 days
• Pulp exposure
• Hemorrhagic versus Necrotic

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Pulp Therapy in Pediatric Dentistry--A Review--
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Pulp Therapy in Pediatric Dentistry--A Review--
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Pulp Therapy in Pediatric Dentistry--Clinical
Assessment of Pulp Status--

• Pulp Testing
• Percussion Testing is most reliable in primary
  teeth.
• Thermal sensitivity Testing is also reliable in
  primary teeth.
• Electrical Pulp Testing is NOT reliable in
  primary teeth (due to the patients response).

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Pulp Therapy in Pediatric Dentistry--Clinical
Assessment of Pulp Status--

• Radiographic Examination
• Radiographic evidence of pulpal pathology
  includes
• Pathologic bone resorption.
• In the presence of infection, bone is destroyed.
• The bone destruction is seen in the furcation
  area of the tooth.
• When the infection is chronic and long-standing,
  the resorption can become extensive involving not
  only the furcation but the apical areas as well.
• The finding of bone resorption is indicative of
  widespread pulpal necrosis and nonvitality of the
  associated tooth.

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Pulp Therapy in Pediatric Dentistry--Clinical
Assessment of Pulp Status--

• Radiographic Examination
• Radiographic evidence of pulpal pathology
  includes (continued)
• Pathologic root resorption. Commonly associated
  with pathologic bone resorption is resorption of
  the root of the affected tooth itself. Root
  resorption is indicative of the presence of the
  infection for a prolonged period and generally
  precludes the employment of any pulp therapy
  procedure.
• Internal/External resorption. If present, it
  will probably be seen in the root canals and
  again is evidence of advanced degenerative
  changes throughout the pulp. Pulp therapy will
  generally not be successful as the resorptive
  process is not readily retarded.

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Pulp Therapy in Pediatric Dentistry--Clinical
Assessment of Pulp Status--

• Radiographic Examination
• Radiographic evidence of pulpal pathology
  includes (continued)
• Calcific changes. Calcified bodies (known as
  calcific masses or globules) present in the pulp
  indicate advanced pulpal degeneration with
  inflammation spread throughout the coronal
  portion of the pulp.
• Widened periodontal membrane/ligament. A widened
  PDL is usually indicative of pulpal pathology.

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Pulp Therapy in Pediatric Dentistry--Clinical
Assessment of Pulp Status--

• There is a poor correlation between clinical
  symptoms and histologic pulp status.

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• The treatment objectives for vital pulp therapy
  include
• Eradication of infection.
• Maintenance of tooth/teeth in a state of health.
• Preservation of space for underlying permanent
  tooth/teeth.
• Capitalization of reparative ability of the pulp.

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Techniques of Vital Pulp Therapy
• Indirect pulp cap/treatment (IPT) Gross Caries
  Removal
• Direct pulp cap/treatment (DPT)
• Pulpotomy (formocresol)
• Pulpotomy (other categories of medicaments)
• Pulpotomy (non-pharmacotherapeutic)
• Partial pulpectomy

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Indirect Pulp Cap/Treatment (IPT)
• Definition In essence, an IPT is the
  application of a drug over a minimal amount of
  carious dentin with no clinical exposure of the
  pulp with the objective of generating reparative
  dentin formation beneath the carious lesion.
• Indicated when the chance of pulp exposure with
  complete caries removal is 75 .
• Place calcium hydroxide (Dycal) or other
  medicament (i.e. Vitrabond, Fuji II, etc.) over
  remaining caries.
• The temporary restoration and marginal seal are
  key to success.
• Can be done in primary and permanent teeth.

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Primary Tooth Direct Pulp Cap/Treatment
• Contraindicated for carious pulp exposures
• Valid for small mechanical or traumatic exposures
• Optimal chance for favorable prognosis depends on
  case selection
• At UKCD, direct pulp caps on primary teeth are
  not considered ideal or acceptable treatment
• Permanent Tooth Direct Pulp Cap/Treatment
• Valid for carious lesions in close proximity to
  pulp but not carious exposures
• Valid for mechanical or traumatic exposures
• Case selection is critical

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Pulpotomy (Pharmacotherapeutic)
• Objectives
• Preserve vitality of radicular pulp
• Amputate infected coronal pulp
• Treat remaining pulp with medicament
• Neutralize residual infectious process
• Avoid dystrophic pulpal change
• Avoid breakdown of periradicular area
• Indications
• Mechanical or carious exposure
• Inflammation limited to coronal pulp
• Absence of spontaneous pain
• Absence of swelling or alveolar abscess formation

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Pulpotomy (continued)
• Contraindications
• History of unprovoked toothache
• Presence of fistula or swelling
• Evidence of necrotic/irreversibly damaged pulp
• Uncontrolled pulpal hemorrhage
• Periapical or bifurcation radiolucency
• Pathologic resorption of pulp
• Dystrophic calcification
• Primary root length less than 2/3

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy
• Success Rate
• 62 to 97 (depending on the study and follow up
  protocol)
• Clinical Success Radiographic Success
  Histological Success
• Formocresol is the standard against which
  pulpotomy alternatives are rated.

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Actions of Formocresol in Pulpotomy Technique
• Fixation with progressive fibrosis
• Acidophilic zone fixation
• Pale staining zone atrophy
• Broad zone of inflammatory cells
• Bactericidal
• No dentinal bridging

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Local Toxicity
• Ranly, 1984
• Histologic failurepersistent chronic
  inflammation
• Immunologic risk
• Succedaneous tooth damage
• Effect on exfoliation (accelerated?)
• Lack of resorbability

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Tissue Effects
• Highly toxic to cells
• Depresses fibroblastic respiration and matrix
  synthesis
• Blocks RNA and protein synthesis
• Chronic inflammatory response
• May be a systemic concern when doing multiple
  treatments (i.e. OR case)

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Dilution of Formocresol (Morowa, Garcia-Godoy)
• 1/5 dilution
• 1 part formocresol
• 3 parts glycerin
• 1 part distilled water
• Comparable to full strength in terms of histology
  and clinic success
• Neither produces ideal histology
• Long-term clinical success of 1/5 dilution is
  questionable
• At UKCD, we use Buckleys Solution (19
  Formaldehyde, 35 Cresol, and 17.5 Glycerin)

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Time of Formocresol Application
• Direct relation between application time and
  inflammation
• One minute produces less inflammation than 5
  minutes
• Neither time shows inflammation in apical third
• Prevalence of Formocresol Use
• The majority of pediatric dentists worldwide
  (76.8) utilize full-strength formocresol or the
  one-fifth dilution as the preferred pulpotomy
  medicament for vital primary teeth (Fuks, 1991).

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy Technique at UKCD (Primary
  Tooth)
• Identification/Diagnosis of offending tooth based
  upon diagnostic criteria (history, symptoms,
  radiographic and clinical evaluation)
• Can Vital Pulp Therapy provide adequate and
  appropriate care for the patient?

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy Technique at
  UKCD(continued)
• Obtain Informed Consent
• Explain to the parent/legal guardian the
  procedure. Answer any questions to his/her
  satisfaction. Document in the chart that you
  have been granted verbal consent for the
  pulpotomy procedure.

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy Technique at
  UKCD(continued)
• Achieve adequate anesthesia
• Place Rubber Dam
• Rubber Dam Placement/Utilization is a Necessity
  when performing pulp therapy!

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy Technique at UKCD
  (continued)
• With a slow speed hand piece, remove caries

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy Technique at
  UKCD(continued)
• 6. With a high speed hand piece and a 330 bur,
  remove roof of pulp chamber exposing all canals

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy Technique at
  UKCD(continued)
• 7. Remove all coronal pulp with a slow speed hand
  piece and a 4 or 6 round bur. Remove all vital
  tissue ledges near canal orifices.

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy Technique at
  UKCD(continued)
• After all coronal pulp tissue has been removed,
  wet 2-3 cotton pellets with formocresol and
  squeeze between
• 2 x 2 gauze to remove the excess. Place cotton
  pellets in the pulp chamber (making sure that
  they contact the pulp tissue in the coronal
  portion of the canals) for 5 minutes.

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy Technique at
  UKCD(continued)
• If hemorrhage has ceased, place a thick mix of
  zinc oxide and eugenol paste into the chamber
  (use an amalgam carrier and a cotton pellet to
  ensure proper condensation/placement).

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--

• Formocresol Pulpotomy Technique at
  UKCD(continued)
• 10. Complete the planned restoration. A tooth
  having had vital pulp therapy will require full
  coverage protection (i.e. Stainless Steel Crown)
  for long-term success.

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Pulp Therapy in Pediatric Dentistry--Vital Pulp
Therapy--
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