Management of the grossly carious primary molar is a common but sometimes challenging aspect of dental care for young

children The first treatment decision for the young patient with one or more extensively carious primary molars is whether to retain or extract these teeth

Diagnosis

The dental problems must be assessed before a treatment plan is designed

It

is important to try to provisionally diagnose the likely pulpal status of the tooth concerned, Clinical signs and symptoms Special investigations

Clinical signs and symptoms

The following symptoms and clinical signs are likely to be associated with significant pulpal inflammation and pathology: Any history of spontaneous severe pain, particularly at night Reported pain on biting The necessity for analgesics

Clinical signs and symptoms

The clinical extent of the caries, notably the presence of marginal ridge breakdown

Clinical signs and symptoms

The presence of any intra-oral swelling or sinus A history of intra-oral or facial swelling

Special investigations
1 Gentle finger pressure may determine whether the tooth is mobile or tender 2 Pulpal sensibility testing is not appropriate for primary molars

Special investigations
3 Radiographs are mandatory to provide information about The extent of the caries and the proximity to pulp horn Presence of any periradicular pathology Degree of pathological or physiological root resorption Presence of a successor

Bitewing

Periapical

Indications for pulp treatment

Medical

factors

Patients at risk from an extraction (e.g. bleeding disorders, hereditary angiooedema) Patients at risk if a general anaesthetic is required for tooth removal (e.g. cystic brosis, muscular dystrophies)

Indications for pulp treatment

Dental factors
Minimal number of extensively carious primary molars likely to require pulp therapy (<3) Hypodontia of the permanent dentition Where prevention of mesial migration of rst permanent molars is desirable

Indications for pulp treatment

Social factors
A regular attender, with good compliance and positive parental attitudes

Indications for tooth extraction

Medical factors
Patients at risk from residual infection (e.g. immunocompromised, susceptibility to infective endocarditis)

Indications for tooth extraction

Dental factors
Tooth unrestorable after pulp therapy Extensive internal root resorption Large number of carious teeth with likely pulpal involvement (>3)

Indications for tooth extraction

Tooth close to exfoliation (>2/3 root resorption) Contralateral tooth already lost (in the case of a rst primary molar, and if indicated orthodontically) Extensive pathology or acute facial swelling necessitating emergency admission

Indications for tooth extraction

Social factors
An irregular attender, with poor compliance and unfavourable parental attitudes.

Extraction and replacement with a prosthesis

Local Anesthesia
Surface Injection

anaesthesia

Topical anaesthesia
Sprays Solutions Creams Ointments

Lidocaine 5% cream Benzocaine 20% cream

Topical

Dry area of application 2. Anaesthetic applied over a limited area 3. Anaesthetic applied for sufficient time
1.

L.A Techniques

Infiltration anaesthesia Inferior alveolar nerve block Intrasseous

Intra-ligamental

Interseptal

Maxillary infiltration
0.5

to 1.0 ml is sufficient for pulpal anaesthesia of most teeth in children Onset of pulp anesthesia: 3-5 min Duration :30-60 min

IAN block
Introduce

the short needle from the primary molars of the opposite side and syringe held parallel to the mandibular occlusal plane of insertion about 5mm above the mandibular occlusal plane

Point

Onset of pulpal anesthesia: 10-15 min Duration: 90 min and sometimes up to 2.5 hours

Rule of 10
Age of patient + number of the tooth

If < 10 infiltration has a good chance of working If 10 infiltration not enough alternative

Examples 8 year + (D) 4 = 12 4 year + (D) 4 = 8

Interseptal
Deposition

of LA in porous alveolar bone (base of the interdental papilla) Minimal soft tissue anaesthesia Minimum amount of anaesthesia required Leakage of LA solution (taste)

Interseptal

Interseptal
Apply

pressure and advance further 1 2 mm ml in 20 sec

0.2-0.4

Blanching

Intraligamental
Also called periodontal ligament anaesthesia Old technique 1912 to 1923 in local anaesthetic books

Technique

Insert a 27 or 30 gauge needle at ~ 30 degrees to the long axis of the tooth into the gingival sulcus
mesial and distal of the tooth Advance needle until there is firm resistance

Technique

Do Not inject too quickly (15 sec per depression)

Wait 15 sec after injection before remove needle Onset is rapid Duration of pulpal anesthesia 10-20 min

Advantages of Intraligamental

Localized area (one tooth) without extensive soft tissue anaesthesia Minimal amount of anaesthesia used 0.2ml per root Rapid onset Alternative to block

2 % lidocaine 1:100,000 epinephrine =2 gm/100ml= 2000mg/100ml=20 mg/ml =1gm/100000ml=1000mg/100000= 0.01mg/ml

Articaine 4%

Ubistesin 1/200 000 solution for injection

For routine-type interventions during minor procedures Articaine 4% Epinephrine (Adrenaline) 1:200000

Ubistesin 1/100 000 solution for injection (Ubistesin forte)

For complicated procedures requiring prolonged anaesthesia Articaine 4% Epinephrine (Adrenaline) 1:100000

Buccal infiltrations of articaine with epinephrine did not differ in their efficacy in obtaining pulpal anesthesia for mandibular permanent first molars.

Ian P. Corbett et al :Articaine Infiltration for Anesthesia of Mandibular First Molars JOE Volume 34, Number 5, May 200

Pulp of primary teeth

Relatively larger Pulp horns are closer to the outer surface Great variation in size and location Mesial pulp horn is higher Pulp chamber shallow Form of the pulp follows the external anatomy Usually a pulp horn under each cusp

Treatment options in primary teeth

Indirect pulp capping Used in case of deep carious lesion (class I) approximating the pulp without signs and symptoms of pulp degeneration The caries surrounding the pulp is left in place to avoid pulp exposure and is covered with a biocompatable material

Materials
Calcium hydroxide should be followed by glass ionomer cement or reinforced zinc oxide eugenol to prevent microleakage since the calcium hydroxide has a high solubility, poor seal and low compressive strength Dentine bonding agents Resin modified glass ionomer

Indirect pulp capping should be followed by a good restoration that prevents microleakage It is not necessary to reenter the primary tooth to remove residual caries after indirect pulp capping as long as there is a good seal and secondary dentine forms

Advantages if IPC

Has a high success rate in long term studies even higher than pulpotomy Normal exfoliation time of teeth

Direct pulp capping

It is not preferred in decidous teeth and has a low success rate Pulpal inflammation usually persists and results in total pulp necrosis An exception is a small mechanical exposure on vital symptom free tooth which is already isolated with a rubber dam

Pulpotomy

Indicated in cases of pulp exposure due to caries removal or mechanical pulp exposure but without radicular pathology

The coronal pulp is amputated and the rest of radicular pulp is treated with a long term clinically successful medicament

materials
Buckleys solution of formocresol Ferric sulfate Gluteraldehyde Electrosurgery MTA Others (BMP, collagen)

Success rates
Formocresol and ferric sulfate have the same long term success rates The highest success rate was for the MTA Electrosurgery, calcium hydroxide and gluteraldehyde had a lower success rates than FC and FS

 Concern

over the use of formaldehyde

This resulted in the withdrawal of Buckleys formocresol and all paraformaldehydecontaining devitalising pastes from the majority of teaching hospitals.

Buckleys formocresol
Tricresol 35% Formaldehyde 19% Glycerol 15% Water 31% A dilution of 1/5 th have been shown to be as equally effective and less toxic

A cotton pellet used with only a trace of FC on the pulp stumps for 5 minutes Be aware not to touch the soft tissue it will cause burns It causes fixation of the pulp tissue in radicular pulp Use reinforced zinc oxide eugenol as a base material directly over the pulp stumps

Restore the tooth with proper restorative material (SSC, amalgam, compomer) if bleeding does not stop then the radicular pulp is inflammed and this indicates a pulpectomy

Ferric sulfate
It is an astringent, stops bleeding by agglutination of blood proteins to make a plug that seals the blood capillaries It promotes pulpal haemostasis through chemical reaction with blood It controls bleeding and forms a protective metalprotein clot over underlying vital radicular pulp

 Used

in a 15.5% for 15 seconds on the pulp stumps to stop bleeding Use glass ionomer as a base and not zinc oxide eugenol It is considered to be a good substitute to FC pulpotomy with the same success rate

Pulpotomy should be checked for clinical and radiographic success after 6 months and then yearly

Pulpectomy
Indicated for teeth with irriversible pulpitis or necrotic pulp Difficult on molars due to tortuous and irregular pulp canals Beware of tooth buds

The canals should be debrided and irrigated with normal saline 0.9%, chlorhexidine solution 0.4% or sodium hypochlorite solution 0.1%

Filling material used in the canals ( non reinforced zinc oxide eugenol, iodoform paste KRI, iodoform paste with non setting calcium hydroxide Vitapex or Endoflax)

Then the tooth restored with a material to prevent microleakage Clinical and radiographic evidence of success should be checked after 6 months There should be no pathologic resorptoin or radicular radioleucency and no signs of abcess or sinus tract

Young permanent teeth

Vital pulp treatment for teeth diagnosed with a normal pulp or reversible pulpitis Treatment options: Indirect pulp capping Direct pulp capping Partial pulpotomy Apexification

Indirect pulp treatment

Used when the tooth has a deep caries and is diagnosed with reversible pulpitis and in this case if all the decay is completely removed endodontic therapy will be needed

In the recent years the focus was to do it as a one step proceedure that is to remove the affected dentine as close as possible to the pulp and use a protective liner, a base and a restorative material that prevents microleakage (no need to reenter the tooth again)

Two step technique (step wise technique)

More recently a two step technique was shown to be succesful in managing teeth with reversible pulpitis due to deep caries and so the technique was revised

Step one

Remove the carious dentine along the DEJ and only excavate the outer most infected dentine leaving a carious mass over the pulp

This has the following objectives 1)Reduce the number of bacteria 2)Close the remaining caries from the biofilm in the oral cavity 3)Slow or arrest the caries development

Step two
Wait for 3-6 months this is to allow provisional diagnosis of pulp status and allow enough time for tertiary dentine formation Reenter the tooth and remove the rest of caries (dentin will be darker, harder and dry resulting in shrinkage of the tissues leaving a void under the restoration) Do your final restoration

Critical for both steps

Seal from microleakage

Follow up
Clinically no signs and symptoms Radiographically normal tooth structure and most important in immature teeth with open apex is continued root development (Apexogenesis )

Direct pulp capping

Highly vascular pulps with great healing capacity. No instrument should be inserted into exposure site Bleeding should be controlled with sterile cotton pellet NOT with a blast of air from 3 in 1 syringe Dentin bridge formation

Partial pulpotomy
Used in immature permanent teeth diagnosed with normal pulp or reversible pulpitis when there is exposure due to caries or trauma

Proceedure
Control the pulp bleeding using irrigation with a bactericidal agent like sodium hypochlorite or chlorhexidine Remove 1-3 mm (or more) below the exposure site using a sterile high speed diamond round bur with good cooling The bleeding should be controlled in minutes if not then go deeper to remove inflamed pulp tissue

Cover the site with calcium hydroxide or MTA The calcium hydroxide has a good success rate but the MTA has a more predictable action In case of MTA 1.5 mm thickness is used Then cover with a layer of resin modified glass ionomer to ensure seal then the final restoration

Follow up
Clinically no sign and symptoms Radiographically continue root development, no internal or external resorption, no abnormal canal calcification and no lesions

Non vital pulp treatment

Root formation not completed in immature young teeth and this development of the root will stop in case of pulp necrosis and eventually tooth will be lost

Apexification

It is the process of inducing root end closure of an incompletely formed non vital permanent tooth by removing the non vital coronal and radicular pulp just short of the root end and placing a biocompatible material

Procedure
After removal of the necrotic pulp debris put a non setting calcium hydroxide dressing for 2 weeks then irrigate and dry canal Do not weaken dentine walls with too much filing Take a WL and put your non setting calcium hydroxide and seal the tooth properly

The apical seal takes 9-12 months to form You have to change the dressing every 3 months Check your barrier with a paper point and radiographically When the apical barrier has formed you can obturate the canal with GP up to the level of barrier formation

MTA composition
Tricalcium silicate Dicalcium silicate Tricalcium aluminate Tetracalcium aluminoferrite Gypsum Bismuth oxide (to detect the material on radiograph) The grey MTA contains iron

Procedure
Necrotic tissues should be removed from canal and it was suggested to use nonsetting calcium hydroxide as an intracanal medicament for 2 weeks After that irrigate and dry canal use the MTA to make an apical barrier and plug it for 4mm at least using special MTA pluggers

MTA needs 4-6 hours to set in humid conditions so seal tooth with a moist cotton Next day obturate using GP and finish your treatment

Necrotic Pulp regeneration using stem cells

The canal disinfected without mechanical instrumentation but with copious irrigation with 5.25% sodium hypochlorite use of a mixture of ciprofloxacin, metronidazole, and minocycline (triantibiotic paste) A blood clot was produced to the level of the cementoenamel junction to provide a scaffold for the ingrowth of new tissue followed by a double seal of mineral trioxide aggregate in the cervical area and a bonded resin coronal restoration above it.

Thank you