Dentin:
Wide dentinal tubuls;
Additional channels over the pulp horns;
Wide dentinal canals above the root delta;
Pulp:
Maturity level of pulp;
Size of the pulp chamber ;
Width of the root canals.
Degree of development of root canals:
Formation of root walls;
Formation of the apex;
physiological resorption:
Degree of root degradation;
Reactivity of the pulp;
Degree of development of the alveolar
bone.
pre eruptive
periodRoot construction Functional period Root resorption
4 yrs. 5 yrs
Inflammation is a localized protective
response that aims to remove the damaging
agents.
It occurs as a protective reaction against
foreign material that has invaded, most
often microorganisms.
There may be other causes, such as trauma,
toxins, chemical, and physical factors, but
most often, microorganisms are the main.
In the acute form, the classic five symptoms are observed: 1. pain (dolor),
2. fever (calor),
3. redness (rubor),
4. swelling (tumor,)
5. and impaired function (functio leasa).
A series of changes are beginning with the enlargement of arterioles, capillaries, and venules. The blood flow and vascular permeability increase; fluid and plasma protein exudation; migration of leukocytes to the site of inflammation begins. Leukocyte accumulation and activation are central to the pathogenesis of all types of inflammation.
Both forms of inflammation are the result of
activation of the humoral and cellular
responses of the immune system.
The immunological elimination of foreign
elements goes through several stages.
First, in order to be eliminated, any
material or antigen must be identified as
"foreign".
Identification may be specific or non-
specific.
It is done by immunoglobulins (antibodies) or through T-lymphocyte receptors that bind to specific sites (epitopes).
Non-specific forms of identification by which denatured proteins and endotoxins are detected are mediated by complement or by phagocytosis. The binding of the recognition components to the antigen leads to a deepening of the process, initiating the production of pro-inflammatory substances. These mediators alter blood flow, increase vascular permeability, enhance attachment of circulating leukocytes to the vascular endothelium, promote the migration of leukocytes into the tissue, and stimulate the degradation of invading agents.
Denatured proteins and endotoxins are detected
are mediated by complement or by phagocytosis.
The binding of the recognition components to
the antigen leads to a deepening of the process,
initiating the production of pro-inflammatory
substances.
These mediators alter blood flow, increase
vascular permeability, enhance attachment of
circulating leukocytes to the vascular
endothelium, promote the migration of
leukocytes into the tissue, and stimulate the
degradation of invading agents.
There are several reasons for a dental pulp
to become inflamed, but the far the
commonest is as a sequel to dental caries;
Dental caries in primary tooth progresses
rapidly to relatively thin enamel and
penetrates dentin;
The insult from bacterial toxins stimulates
the underlying pulp to respond by mounting
an inflammatory reaction – reversible
pulpitis.
The true immune mechanism for antigen
destruction is by phagocytes.
They can be freely moving or attached to
specific sites in the tissue as elements of the
mononuclear phagocytic system.
Macrophages and related cells, such as Kupffer
and synovial A cells, are central components of
this protection.
The degradation of the antigen outside the
mononuclear phagocytic system is related to
polymorphonuclear leukocytes (neutrophils) or
to monocytes coming from the circulating blood.
The pulp inflammation is influenced by the specificity of the causative agent and by the peculiarities of the pulp.
The pulp is connective tissue but has different anatomy, which determines the physiology and character of the emerging pathological processes.
Beyond these reasons, there is a specificity in childhood that further changes the nature of the reactions that occur, and this affects the whole process, the clinical picture, diagnosis, and treatment.
Primary teeth pass through their three developmental stages in just a few years – (1) embryonic, continuing until the end of root formation, an extremely short (2) functional period, and a prolonged (3) period of resorption.
During embryonic pulp development (two years after the eruption), the pulp is active and well protected both through all the young elements in it and the vitality of the growth zone.
- Another advantage is the short functional period, which does not allow the development of gradual changes with the loss of function of all its elements, as happens with the aged modified pulp of permanent teeth.
- During root resorption, the pulp is also active and well protected by the resorptive organ. It is highly vital, and, similar to the root formation, the wide apex ensures proper drainage of inflammatory products. That avoids the anatomical deficiency of the pulp location (the pulp is surrounded by solid mineralized dentin). At the same time, the resorption organ also provides protection through its young granulation tissue with an abundant blood supply.
The development of inflammation in the pulp
is completely different.
The pulp is closed inside the tooth and is
surrounded by dentin and enamel in the
crown.
In order to engage the pulp, an enamel and
then a dentine carious lesion must first
develop.
These lesions are the way to get the irritants
into the pulp.
Carious destruction of enamel and dentin is a chronic process.
It progresses with months and sometimes with years.
As the carious destruction approaches the pulp, the dentin permeability increases.
It creates an opportunity for the entry of ions and metabolic products released by the microorganisms into the carious defect. They cause a reaction from the pulp.
Recent studies have shown that when small doses of irritants enter the pulp chronically as a consequence of a developing carious lesion, slightly progressive chronic inflammation occurs in a small area.
It usually begins without the development of any prior acute response.
In an untreated dentinal carious lesion, bacterial products move along the dentinal tubules, which are wide and reach the pulp before microorganisms.
Antigenic bacterial products activate the immune response.
Due to the lower toxicity of the bacterial products, they cause activation of a cell-response, in which the macrophages play a significant role.
1) invading stimuli through the dentinal tubules;
2) odontoblasts;
3) neuropeptides and neurogenic irritation;
4) innate immune cells, such as immature
dendritic cells, natural killer cells, and T cells;
5) their cytokines and
6) chemokines.
Although the first two elements are not classic
components of innate immunity, they are the
unique elements that give specificity in
unlocking the pulp inflammatory response.
It is accompanied by the accumulation of lymphocytes, plasma cells, and macrophages - a characteristic feature of chronic stroke.
Inside the inflammatory infiltrate are immunocompetent cells corresponding to the carious lesion diffusing antigenic substances.
There is a proliferation of small blood vessels and fibroblasts that begin the production of collagen fibers.
The goal is to limit and isolate the inflammatory response and to maintain the underlying pulp.
This type of the pulp inflammatory response is known as a protective one.
It has been found that with a carious lesion
of 1 mm to the pulp, the inflammatory area
is insignificant.
With the reduction of preserved dentin to 0.5
mm, the inflammatory response progresses
and increases, but for a long time does not
cause exacerbation of inflammation.
This is the reason why it is possible to use
biological treatments for tissue repair.
It is the early involvement of the pulp in
inflammation while the great protection is
leading to chronification of the
inflammation, in which the pulp retains its
function.
Childhood creates favorable and unfavorable
conditions for the development of pulp.
a. Active tissue metabolism and protection.
b. Possibility to remove inflammatory
products, microbial toxins, and
microorganisms.
c. Opportunities to limit chronic
inflammation and preserve the function of
the remaining pulp.
d. Possibility of re-development of
inflammation leading to the recovery of the
affected tissue or true healing.
a. With the prevalence of inflammatory agents over the protection of the pulp tissue, the inflammation quickly passes from one phase to another, and the chronic inflammation rapidly exacerbates.
b. All the protective factors of the young pulp accelerate exacerbation and the progress of inflammation.
c. The lack of apex in the two teeth and root resorption during the temporary development of irreversible pulp inflammation leads to very rapid involvement of the periapical structures.
d. Irreversible pulp inflammation can only develop into periapical for hours.
e. In the case of irreversible pulp inflammation in teeth with incomplete root development and root resorption of the temporary tooth, it is impossible to apply routine endodontic methods of treatment.
Infection:
For deep cavities;
Secondary caries;
It is caused by:
microorganisms;
Microbial toxins;
Dentinal degradation products.
Microorganisms
Exo-and endotoxins
Degradation of odontoblastic processes
They are moving through dentine tubules
They are reaching to odontoblasts and nerve receptors
Is induced reflective Overcoming
reaction protection
Protection
When compensatory
mechanisms are running out
Inflammation
Exudation;
Alteration;
Proliferation.
Serous inflammation
Serum diapedesis
Plasma diapedesis
Pulp abscess
Cell diapedesis
Increase granular
cytoplasm
Relocation of nuclei
in dentine tubule
Disoriented odonto-blasts
Damage to the pulp-
dentin border
Destruction of the odonto-blasts
Depoly-merization
of the inter-
cellular space
Degradation of collagen fibers
Destruction of the vascular
walls
Develops chronic
ulcerative pulpitis
Chronic pulpitis
development of fibrosis
fibrous pulpitis
Growth of young granulation tissue
granulomatouspulpitis
Causing a massive increase in pulpal
response;
This is characterised by irreversible
inflmmation and tissue necrosis directly
adjacent to the site of exposure;
Bacteria and their products will progress
through the pulp tissue, resulting in
irreversible inflammation;
The response of pulpal and periodontal
tissues to such injury can lead to one of
several outcomes:
The periradicular tissues may affected
(periradicular periodontitis), with eventualy
involvement of associated tissue;
If the exposure site involves a large area,
Hyperplastic pulpitis (pulp polyp) may occur;
The tooth may be subject to pathological
resorption – for example, internal
inflammatory resorption.
A classification divides the pulp into two
groups - reversible and irreversible.
Depending on the symptoms, they are
divided into symptomatic and
asymptomatic.
Depending on the communication of the pulp
with the carious lesion, pulpitis is divided
into open and closed.
1. Reversible pulps:
a. Pulpitis asymptomatica clausa.
b. Pulpitis asymptomatica aperta.
2. Irreversible pulps:
a. Pulpitis symptomatica clausa.
b. Pulpitis symptomatica aperta.
History -unreliable; Clinical examination:
Visualexamination
Probe Percussion
Paraclinicalexami-nations
Depth of the carious destruction;
The color of carious dentin;
Communication with the pulp;
Smell of carious defect;
Redness of periapical mucosa;
Fistula.
Consistency of the carious
dentin;
Carious dentin
thickness;
Tooth motility.
Radiography (not at
pulpitis);
EPD (not at primary
dentition)
Child crying;
Waking up in the night;
Whether or not there a swelling;
Big carious defect
Emergency treatment on the same day
Transient pain
Long lasting pain
Presence of fistula
Urgency will appear at any moment.
Initially each pulp inflammation is a chronic process;
Practically there is no acute pulpitis;
There are exacerbation of existing chronic pulp inflammation;
The teeth pulp has good recreational opportunities.
Reversible pulpitis
Closed
Asymptomatic
Opened
Irreversible pulpitis
Closed Opened
Symptomatic
Pulp Therapy in the
Primary teethThe treatment plan should be based
on specific diagnosed findings,
medical status and the child's
behavior, social status of the family.
Reversible - closed asymptomatic pulpitis;
Large carious lesions without pulp symptom
"pain";
Pulp symptom "pain" is missing:
Spontaneous pain;
Night pain;
Provoked pain - over 1 min;
Occurrence of pain while eating or irritation
in carious lesions still does not mean pulp
symptom "pain".
Diagnosis of childhood pulpitis is performed
in several steps, the purpose of which is to
differentiate reversible from irreversible
stages of pulp inflammation.
It is necessary to identify the presence of
pulp communication and to take into account
the type of symptoms that reveal the
diagnosis.
The most crucial first step is to decide when
a carious lesion indicates that the pulp may
be involved in inflammation. It should be
done through a differential diagnosis
between caries, pulpitis, and pulp necrosis.
When sufficient suspicion for pulpitis is present,
the second step is to determine the nature of
the inflammation. Most important is the
differentiation of reversible stages of
inflammation. Only they can be treated to
preserve the vitality and function of the pulp.
They require special treatment. In irreversible
pulpitis, treatment possibility is significantly
limited and does not depend on the nature of
inflammatory exudation. In all cases, it is
sufficient to establish irreversibility, which
requires the complete removal of the pulp and
then the tooth restoration.
1. History of the disease.
2. Clinical signs and symptoms.
3. Thermal stimulation.
4. EPD diagnosis.
5. X-ray examination.
6. Modern diagnostic methods.
If the child comes for a prophylactic
examination, the anamnesis will not be
specifically targeted for the presence of
pulpitis but will be a standard data collection
for the individual's development, his or her
general medical and dental history.
The chronic pulpitis will only be passably
detected during the intraoral examination
when large carious lesions.
The main symptom of pulpitis is severe pain. The presence of pain allows distinguishing between symptomatic and asymptomatic pulpitis.
The presence of a symptom of "pain" is a clear sign of symptomatic pulpitis.
The name "asymptomatic pulpitis" does not mean that the signs of developing pulpitis are missing, but only the characteristic symptom of "pain" is missing.
The symptom pulp pain shows irreversible pulp inflammation. It occurs when there are so many irritants accumulated by the inflammation that the tissue with all its protective mechanisms cannot cope with. Then the nerve fibers are excited not by external stimuli form carious lesions during eating but by the pulp inflammation.
The first characteristic of irreversible pulpitis is spontaneous pain.
It occurs suddenly, has a sharp character, lasts differently depending on the duration of the process.
At this stage, the pulp protection is not completely destroyed, but only temporarily overcome.
In the initial stages of irreversible pulp inflammation, spontaneous pain is short and has long remissions.
The more the process progresses, the longer the pain becomes and the shorter the remissions are.
It is important to get information about the beginning of the pain and how long it has lasted.
When the pain occurs during sleep, it is a
sure sign of irreversible inflammation.
The question is whether the child woke up
crying of toothache, how this pain subsided,
or whether a painkiller was given to restore
the sleep.
We must be informed when occurred the first
awakening, how many times per night, how
long the attacks were.
It is difficult for the child to register the first
disease symptoms.
At the same time, even if it has been
recorded, it cannot characterize them and
then formulate them.
The parent is usually the main source of
information about the disease, especially in
pre-school children.
In infants, the only source is the parent.
All available data;
Existing complaints;
The general medical and dental history of
the child;
Complaint history at the moment.
Is there any evidence of pain;
Presence of spontaneous pain;
Presence of night pain;
The pain of cold, warm and sweet while
eating;
Pressure pain while eating;
Retention or duration of pain after irritation.
1. Do you feel anything when eating ice cream?
2. Do you feel something when you eat warm food, such as soup?
3. What happens when you eat something sweet, such as candy?
4. Do you sometimes wake up in the evening with a toothache?
5. Does this last long?
6. Does it hurt if you hit your tooth with a toothbrush or a fork or spoon?All available data on symptoms available should be verified and refined in the next study.
Before a clinical examination, we should
keep in mind the usual course of caries
development and its complications in
childhood:
- Carious lesions - usually in primary dentition
develop after the third year, in early childhood
caries after the first year;
- Pulpitis - in primary dentition - after the fourth
year, in early childhood caries - after the second
- Periapical inflammation - in a primary dentition
- after the fifth year, in early childhood caries -
after second years.
We perform a comprehensive examination to
determine extra- and intraoral status, and
targeted examination is performed only for
the teeth that arouse suspicion.
The dental status is established, but the
examination is directed to the jaw and the
side of the suspected tooth.
When a large dentine carious lesion is
detected in the dental status examination,
the corresponding tooth is subjected to a
basic examination to determine the
diagnosis.
In this process, a differential diagnosis
should be made between a carious lesion,
pulpitis, and periodontitis, as in all three
cases, a major carious lesion can be
identified at the first examination.
Cavitated or not cavitated.
Depending on location, lesions are occlusal,
approximal, and cervical.
- depth of the lesion;
- contours of the lesion;
- the hardness of carious dentin;
- affected cusps;
- pulp opening.
Every deep carious should be thoroughly examined.
In addition to its external dimensions, the lesion must be examined in depth.
The examination should be done through careful deliberation rather than deep probing (the probe should not be used to seek pulp communication).
The focus of the study is now on the diagnosis of reversible pulpitis, of which closed asymptomatic pulpitis is the most favorable for biological treatment.
Rough drilling seeking communication with the pulp is a rude mistake in the diagnostic process.
In order to determine whether the depth of the lesion corresponds to the affected pulp, some features of the children's teeth must be considered.
The first is that the depth of fissures in primary
molars is not great, since the enamel in this
tooth is the same thickness in all sections - 1
mm, and this reduces the risk of developing
occlusal caries compared to permanent teeth.
The dentin immediately below the fissure is
thicker, and this determines the longer course of
occlusal caries.
As a final result, in the study of occlusal caries in
primary teeth, relatively deep occlusal carious
lesions may be found that are not necessarily
related to the development of pulpitis.
The size of the approximal destruction
should be considered.
The contact between primary teeth is wide
rectangular, at all over the approximal
surface. A reason for it is the enamel swelling
in the cervix.
The enamel and dentin are thinner.
Thus, usually, the approximal lesions of the
primary teeth may not be deep at all, but at
the same time be dangerously close to the
pulp.
The superficially exposed pulp horns.
In primary teeth, such as the first lower primary molar, the pulp horn is 1.5 mm below the enamel surface.
In this case, an approximal carious lesion reaches the pulp horn extremely fast, and pulpitis develops.
In approximal lesions of the primary teeth, the depth is not the leading criterion, but the degree of involvement of the approximal wall.
When a shallow carious lesion but the entire approximal surface is covered, the most likely diagnosis could be pulpitis.
They are the rarest lesions in the primary
dentition.
The reason is the enamel, and the equally
thickness of 1 mm enamel layer even in this
area.
The lesion develops relatively slowly and
only in extremely aggressive environments
would be associated with pulpitis
The borders of the lesion are of utmost importance for the diagnosis of pulpitis;
In cavitated lesions, we should keep in mind that the dentin lesion is sometimes significantly wider than the observed cavitation.
We should look for a change in the enamel color at the periphery, which will be much better suited to the actual size of the lesion.
We are looking for the proximity of the carious lesion to the pulp horns, located just below the tip of the cusp.
We have to measure the distance between
the borders and the tip of the closest cusp.
If the borders are close to 1/2 of the
distance between the deepest point of the
fissure and the tip of the cusp, the pulp may
have been affected.
When caries dentin is removing, this must be
done with special care to avoid an incorrect
and unnecessary pulp opening.
If the lesion occupies most of this distance,
we can be sure that it is pulpitis.
We have to measure the distance from the
end of the lesion to the tip of the closest
cusp, and if it is equal to or more than half,
the most likely diagnosis is pulpitis.
The discoloration of the caries affected dentine
varies depending on the deposited pigments
from the breakdown of the affected structures.
The speed of development of the carious lesion
determines the degree of these pigments.
The faster a carious lesion develops, the fewer
pigments are deposited and usually, the color is
yellow to light brown.
In the chronic process, the more pigments are
deposited, and the color is dark brown to black.
The darker the carious dentin, the less the
possibility of pulp engaging is present.
The hardness of carious dentin is also an
indirect sign of eventual involvement of the
pulp, as it is crucial for the rate of
progression of carious destruction.
Soft consistency is a fast-paced process that
is more likely to develop pulpitis.
The solid texture speaks of a slow process
that is conducive to activating the protection
of the pulp-dentin complex and is more likely
to be caries.
When the carious lesion is so large that even
one of the molar cusps is destroyed, pulpitis
is the most likely diagnosis.
It is done with the help of a mirror and using air drying. It makes visible pulp opening.
The presence of ulcers is sought. Probing is not recommended because it is not necessary to establish disclosure.
If disclosure is present, probing is contraindicated. Such probing would be painful and would also disrupt the fibrous barrier in the pulp around the chronically developing ulcer. It stimulates the spread of the infection, which would ruin biological treatment.
If the pulp is detected and spontaneous or night pain is missing, the diagnosis is pulpitis asymptomatica aperta.
If no finding is made, the study continues to establish the differential diagnosis between caries and pulpitis asymptomatica clausa.
The application of agents with different
temperatures to the teeth stimulates pulp
sensory responses.
It is not applicable in primary dentition.
Large cavitated carious
lesions with:
1.Soften lighter or darker
carious dentin;
2. Lack of disclosure of the pulp
(pulpitis closed);
3. Cavitation affects closest
cusp;
4. The reserved portion is less
than ½ of the distance between
the tip of the cusp fissure.
Carious process covered the much of the occlusalsurfaces;
There is no disclosure of the pulp.
But staining of the enamel is in the vicinity of the tip of the nearest cusps;
Incolored dentin is below ½ of the distance between the bottom of the fissure and the tip of the cusp - closed pulpitis;
The size and location of cavitationcorrespond of pulpitis;
Absent disclosure;
Large carious
lesions with the
disclosure of the
pulp amongst
carious dentin;
Open pulpitis.
Absence of pain symptoms:
• Absence of night pain;
• Absence of spontaneous pain;
Permissible pain symptoms
• pain of cold, sweet and pressure at meals that disappear after removing the challenge;
Carious lesion is close to the pulp, a thin and
partially demineralized dentin over the pulp
horn.
Not be taken due to the subjective reaction of small children.
When it comes to tooth caries, you may remove the entire carious dentin over the pulp, even in the area of pulp horn without disclosing the pulp;
Over the pulp horn or at the bottom remains thin, sometimes colored, but durable and well mineralized dentin.
Clinical findings
Large carious lesions
with or without a disclosure of
the pulp;
Large filling with or without
a defects.
Spontaneous pain;
Nighttime pain;
Pain when chewing or at sweet and cold that does not pass immediately after elimination of the stimulus;
Need to give an analgesic;
Partially or
completely
demineralized
dentin over the
pulp;
Absence of dentin
over the pulp
horn.
There are quite rare;
Treating caries should significantly reduce pilpitis;
Correct treatment of reversible pulpitis should remove them.
Is subject to the biological principle and the minimally invasive approach.
1. Biological principle - minimum removal of the affected tissue or structure and maximum storage of the pulp tissue.
2. Minimally invasive approach - minimally invasive diagnostics, minimally invasive pain management, micro-invasive cavity preparation, minimally invasive carious dentin removed, minimally invasive pulp, and growth zone attitudes in both dentitions.
These principles provide significantly greater preservation of the oral health of adolescents, as well as of their mental and physical well-being.
of "National Association of
Pediatric Dentistry" for the
pulp treatment of primary
teeth
Treatment of reversible pulp inflammation
The most appropriate
method - indirect pulp
capping!
1. Provides treatment of the majority of all primary teeth pulpitis.
2. The easiest;
3. Most atraumatic;
4. The best accepted of children;
5. No anesthesia is required;
6. Provides proven results;
7. Saves the vitality of the tooth;
8. Saves the functionality of the dentition;
9. Ensures correct physiological change.
Argument for the effectiveness of indirect
coverage
First visit
It is the most common reversible pulpitis in primary dentition. The appropriate treatment method is indirect pulp capping. It is a biological and less traumatic operative method.The purpose of the indirect pulp capping is to heal pulp inflammation and preserve the pulp vitality.
It is achieved by:
- stopping the carious spread;
- influencing inflammatory changes in the pulp;
- stimulation of reactive dentin deposition;
- stimulation of remineralization in the over-pulpal dentin.
It can be realized in more than two visits.
While in the caries treatment, the affected
dentin can be safe, in indirect pulp capping,
some of the infected can left behind.
This dentin cannot be permanently retained
but can be used to affect the pulp.
Therefore, it is saving to avoid pulp
disclosure.
Can be used to distinguish healthy from
infected and affected dentin.
It shows the extent of dentin involvement
with discoloration.
The caries detector turns green if the dentin
is healthy. In the case of a thin layer of
demineralized/affected dentine, the caries
detector shows a pale red color. When the
dentin is infected, the caries detector glows
in deep red (Kabakchieva, Milcheva, 2016).
It provides a step-by-step, providing minimally traumatic action for children and the ability to administer even to young and restless children.
The infected dentin is removing gradually while providing sufficient time for the remineralization of part of the infected dentin.
During this time, new protective dentin is also deposited, which provides pulp stability.
When using the caries detector, the color is also changed -it turns pale red.
This means that the underlying dentin is mineralized and allows the treatment completion in the same visit. In some fields have red staining, indicating infected dentin
In these cases, we can repeat the procedure with calcium hydroxide capping to further remineralization and time to thicken the protective newly formed dentin.
First step:
Diagnosis – closed asimptomatic pulpitis;
• The clinical features shows softened carious dentin without exposing the pulp;
• Symptom-free tooth – no “pain symptom” .
1. comprehensive medical history;
2. review of past and present dental history and treatment,
including current symptoms and chief complaint;
3. subjective evaluation of the area associated with the
current symptoms/chief complaint by questioning the
child and parent on the location, intensity, duration,
stimulus, relief, and spontaneity;
4. objective extraoral examination as well as examination
of the intraoral soft and hard tissues;
5. if obtainable, radiograph(s) to diagnose pulpitis or ne-
crosis showing the involved tooth, furcation, periapical
area, and the surrounding bone; and
6. clinical tests such as palpation, percussion, and
mobility
All caries is first cleared from the cavity
margins with a steel round bur running at a
slow speed:
From the cavity margins;
In gingival basis for interproximal defect (maybe
with excavators);
Dentin in the area under the enamel-dentine
border should be healthy, well-mineralized;
Enamel-dentin border must be clearly visible.
1.Gentle excavation than follows on the pulpal floor, removing as much of the softened dentine as possible without exposing the pulp.
2. A thin layer of setting calcium hydroxide is then placed on the cavity floor to destroy any remaining microorganisms and to promote the deposition of reparative secondary dentine;
3. The indirect pulp cap was covered with zinc oxide-eugenolcement for 6-8 weeks;
4. Radiograph observation.
First step:
Radiographic review;
Observe dentin over the pulp - compared to the
first X-ray;
Expected results:
remineralization of demineralized dentin
and formation of new secundary dentin;
The cavity was re-entered to remove all remaining softened dentine;
Periodic clinical and radiographic review is then undertaken to monitor the pulp response
This method is not recommended for
exposed pulp due to caries of primary teeth
from AAPD (2001, 2004, 2009).
Not recommended by the British and IAPD.
Therefore now this method is not
recommended for the treatment of primary
teeth.
Recommended method –
pulpotomiy
To preserve the vitality of the radicular pulp - in primary teeth is difficult to apply and is not currently recommended by any major worldwide organization of pediatric dentistry;
To stimulate tissue regeneration and healing at the site of the of amputation - in primary teeth practically difficult to apply and is not recommended;
To become root pulp in inert mass - real purpose of the primary teeth and this is the easiest method.
Local analgesia;
Apply ruber dam wherever possible;
Remove caries and roof of the pulp chamber, remove coronal pulp;
Apply medicament to radicular pulp on a cotton pledget;
Remove the cotton pledget and check that there is no exessive haemorrhage from the remaining pulpal tissue
15,5% Ferric sulfate - cotton pledget with
medicament placed over the radicular pulp
for 15 sec
20% (1:5 solution) Formocresol (Buckly) for 5
min;
МТА;
Calcium hydroxid;
Acting on the surface of the radicular pulp;
Agglutinate blood proteins and stop bleeding;
It is suitable alternative to formocresol.
The oldest method with the worst results;
In recent years revived but the alternative to success is extraction of the tooth (fully eligible by the IAPD);
Traditionally been used;
There hav been some conserns about its toxivity, both locally and systemically;
It is used a 1:5 concentration Backlyformocresol solution;
It is hold 5 min in pulp chamber (1 min);
Zinc oxid eugenol;
Restore the crown, usually. With a stainless-steel crown.
Equal parts formaldehyde and cresol;
Concentration 1:5 is achieved when:
Three parts of glycerin;
One part of distilled water;
Mix in advance;
These four equal parts were mixed with one part
of the solution to Buckley.
Often results in extraction;
Glutaraldehyde: Formaldehyde is a small molecule, a
glutaraldehyde - large;
Formaldehyde requires a long time for fixation of the tissue - Glutaraldehyde act immediately.
The reaction of the glutaraldehyde can not be reversed.
Can be an alternative for treatment.
Encouraging results;
Require monitoring and evidence in primary teeth;
Require adapted technique;
Requires the cooperation of the child and the parents;
Bad results in primary teeth;
Require monitoring and evidence in primary teeth;
Require adapted technics and cooperation of the child and the parents;
Alternative - extraction of the tooth.
Mortal pulpotomy
Age of the children is not suitable for channel instruments;
The roots are in resorption;
Risk for permanent tooth bud;
The method is easy to use;
With sufficient reliability till time of physiological tooth change.
Desensibilisatio pulpae
Preparatio cavi dentis
Amputatio pulpae
Desinfectio pulpae
Mumificatio
Obturatio
There are two methods:
1. Method of Stransky – 3 visits;
2. 2. Formalin-resorcin method – 2 visits.
First visit: Diagnosis;
Caries removal In order to protect the child from the pain does not
remove the entire caries, but only the one that:
gives access to the pulp;
is a gingival margin (in second class cavity).
Devitalization of teeth by arsenic trioxide
Remove devitalized arsenic trioxide;
Cavity is formed, creating retention;
All caries removal;
Amputatio pulpae;
Desinfectio pulpae;
Mumificatio pulpae.
Caries removal from
cavity margins;
Last caries removal is
from pulp roof.
When the bur passes through the roof of the chamber a “dip” is felt;
Once this is felt the bur is not taken any deeper but moved sideways to remove the roof of the pulp chamber.
Remove coronal pulp
with a large round bur
or large excavators;
Escavators are safer
to avoid perforation
in the furcation
region.
With small round bur is removed the pulp from the root in 1-2 mm.
Liquid-A
Rp/
Tricresoli 20.0
Formalini 60,0
M.D.S./A/
Liquid - B
Rp/
Resorcini 40,0
Aq.destil. 50.0
M.D.S. /B/
Liquid –С
Rp/
Natrii caustici
Kalii caustici 4,0
Aq.dest.
24,0
M.D.S./C/
Mix a paste of:
ZnO
eugenol
thymol
Dense texture-
cover with
powder Zno
Place the equal
drops of liquid A
and B close to
each other. Mix
at the time of
placing in the
pulp cavity
Apart from
them, on the
same plate is
placed a drop
of liquid C.
Dip the cotton
pledget in
mixed liquids A
and B and
place it in pulp
cavity for 1min.
Dried cotton
pledget with
liquid Сput in
pulp chamber
for a second.
Fill the
periphery of the
root canals and
all pulp
chamber with
zinc oxid
eugenol and
thymol cement
for a provisional
filling.
Check for
complications.
If no – the
treatment
continues.
From zinc oxide
thimol cement
is forming a
room for filling.
Restoration.
Trikresol-formalin :
Lipid-soluble compound with the ability to cross
biological membranes;
Can to precipitate microbial cellproteins ;
Violates the lipid metabolism;
There are hydrophilic and hydrophobic groups.
Has antiseptic activity;
Anti-inflammatory activity;
The result of mixing trikresol-formalin-resorcin is a
bakelite;
Potassium sodium hydroxide catalyzed process.
Formation of bakelite became in 2 hours.
Before the formation of bakelite started separating paraformaldehyde: disinfecting;
bactericidal;
dehydrates;
coagulate the protein;
mummification;
Impacting.
Antiseptic:
Precipitated proteins of microbial cell;
Inhibits enzymes in microorganisms;
Dehydrates.
Eugenol - clove oil;
Thymol - oil of thyme herb;
Include:
Phenols and aldehydes;
biologically active substances;
Action:
Antiseptic;
Antiinflammatory;
Local anesthetic effect.
First visite – devitalisation.
Second visit: Caries removal;
Cavity preparation;
Pulp chamber roof removing;
Coronal pulp removing;
Radicular pulp (1-2 mm) removing
Of the sterile
plate is placed
a drop of 40%
formalin and
the tip of the
spatula with
resorcinol
crystal -
supersaturated
solution.
Dip the cotton
pledget and
place it in pulp
cavity for 2-5
min. With the
remaining
amount of the
solution and
zinc oxide stir a
hard paste.
Fill periphery of
the canals and
the base of the
pulp chamber,
with hard zinc-
oxide cement
all pulp cavity,
then -
restoration
Formalin - 40%
Denature the proteins in MO;
Bactericidal action;
Virucidal;
Sporicidal;
Poorly penetrates deeply.
Affect microorganisms and toxic degradation;
Not interfere with the healing process in periodontal and alveolar bone;
Antibacterial action to:
Str.haemolyticus
Str.Aureus
Bactericidal action:
Tricresol formalin - 51% sterility
Resorcin-formalin - 67% sterility