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Medicament's used in pulp therapy of pediatric dentistry
The document discusses various medicaments used in pulp therapy for primary teeth. It describes techniques such as pulp capping, pulpotomy, and pulpectomy. Formocresol and ferric sulfate are commonly used vital pulpotomy medicaments, though concerns exist regarding formocresol's toxicity. Mineral trioxide aggregate and NuSmile NeoMTA are newer alternatives that are non-staining with good clinical success rates. Calcium hydroxide was previously used but causes resorption in primary teeth. Overall, multiple medicaments are available though studies show MTA and ferric sulfate may be favorable replacements for formocresol.
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Medicament's used in pulp therapy of pediatric dentistry
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- 2. Medicaments used inpulp therapy of primary teeth Dr Izhar Ali TMO PAEDIATRIC DENTISTRY, KCD,PESHAWAR. 2
- 3. Introduction • Pulp ofa tooth is susceptible to insult via carious lesion ,trauma or iatrogenic exposure • Removal of inflamed ,infected or compromised pulp tissue is necessary for the underlying radicular pulp and succedaneous tooth 3
- 4. Cont. Important factors whichdetermine the type of endodontic treatment needed are : 1. Exposure – traumatic or carious 2. Vitality – vital or non-vital 3. Apex – open or closed(young permanent tooth) 4
- 5. DIAGNOSIS • Pain • Swelling •Mobility • Percussion • Vitality tests • Radiographs • Depth of the lesion • The exposure site 5
- 6. Treatment techniques • Pulpcapping • Indirect pulp capping • Direct pulp capping • Pulpotomy • Vital pulpotomy techniques – Using calcium hydroxide – Using tissue fixing medicaments » Formocresol » Ferric sulphate » Glutaraldehyde » N2 » Devitalizing paste • Non-vital pulpotomy technique or Two-visit disinfection pulpotomy or Mortal pulpotomy • Pulpectomy (of non-vital teeth) 6
- 7. Pulp capping • Theaim of pulp capping is to maintain the vitality of the pulp 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). • Direct pulp capping • Indirect pulp capping 7
- 8. Pulpotomy The removal ofcoronal pulp and treatment of radicular pulp Vital Pulpotomy The removal of vital (inflamed) coronal pulp tissue, and placement of a dressing (medicament) over the cut radicular pulp stumps to promote healing or fixation of tissue in the canals. Non-vital Pulpotomy The removal of non- vital (infected) coronal pulp tissue and treatment of the non- vital pulp tissue in the canals pharmacologically. 8
- 9. PULPECTOMY • The removalof coronal as well as radicular pulp is called pulpectomy • It needs proper instrumentation into root canals 9
- 10. PULPOTOMY Open pulp chamber Removepulp from pulp chamber Arrest haemorrhage Apply medicament to pulp stumps on pledget of cotton wool Place zinc-oxide eugenol paste in the floor of the pulp chamber Give lining Restore the tooth 10
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- 12. Ideal medicament • Nonirritant to Periapical tissues • Antimicrobial effect • Effective germicide and fungicide • Stable in solution • Should not stain tooth structure • Should not be antigenic • Should not interfere with Periapical healing 12
- 13. Mechanism of action 1.Causingheamostasis and maintenance of vital tissues e:g ferric sulphate solution 2.Dentinal bridge formation and maintenance of vital tissues e:g Mineral trioxide aggregate 3.Superficial/partial pulp fixation and maintenance of vital tissues e:g dilute formocresol solution 13
- 14. COMMENLY USED MEDICAMENTS •Formocresol • Ferric sulphate • Glutaraldehyde • Paraformaldehyde (devitalizing paste) • Beechwood creosote • Mineral trioxide aggregate • Nusmile NeoMTA • Calcium hydroxide 14
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- 16. Composition • Formalin (formaldehyde)37% 19ml • Tricresol (cresol) 35ml • Glycerin 25ml • Water 21ml 16
- 17. Used for Single-visitPulpotomy Success rate 98% • Carious or mechanical exposures in vital primary teeth. 17
- 18. Cont. • Formocresol dippedcotton pellet is squeezed in gauze piece • Proper isolation is compulsory • The pellet is applied to pulp stump keeping care of the nearby soft tissues e:g gingiva ,mucosa etc 18
- 19. Variations • Post amputationbleeding is controlled by placing wet cotton pallet (with some non irritating solution like saline ) • The tooth is considered suitable for single visit formocresol pulpotomy only if bleeding is arrested naturally • If bleeding persists, a two visit pulpotomy or pulpectomy should be performed 19
- 20. Cont. • The orificesof root canals are first covered for 3 minutes and then for another 2 minutes if needed with formocresol to fix the pulp stump at the orifice level . • If bleeding still persist or uncontrolled, It indicates irreversible damage( inflammed /hyperemic ) of radicular pulp and pulpectomy is indicated 20
- 21. Concerns Regarding Formocresol • Localtoxicity • Systemic toxicity • Carcinogenicity and mutagenicity 21
- 22. Diagrammatic Representation of CompletedPulpotomy Final filling Cement Zinc-oxide Eugenol Paste Vital pulp 22
- 23. Ferric sulphate for vitalpulpotomy 23
- 24. Cont. • 15.5% ferricsulphate in an aqueous vehicle • On contact with blood ,it form ferric ionprotien and the membrane of this complex seals the cut vessels mechanically, producing haemostasis. • Thus it acts by blocking capillary blood flow and thus initiating haemostasis without any clot formation. 24
- 25. Technique Open pulp chamber Removepulp from pulp chamber Apply ferric sulphate over the radicular pulp stump for 40 seconds Place zinc-oxide eugenol paste in the floor of the pulp chamber Give lining Restore the tooth 25
- 26. Cont. • Acidic innature • May cause root sensitivity • Tissue irritation 26
- 27. Glutaraldehyde Pulpotomy Suggested byS- Gravenmade in 1975 Success rate about 96% 27
- 28. Advantages • Equally effective •More effective tissue fixation of the coronal portion • More vital tissue remaining in the apical portion of the canal • No dystrophic pulp calcifications 28
- 29. Disadvantage • The solutionshelf-life is only one week 29
- 30. Para formaldehyde (DevitalizingPaste) 30
- 31. Composition • Paraformaldehyde: 1.0g • Lignocaine: 0.06 g • Coloring agent : 0.01 g • Carbowax1500:1.3g • Propylene glycol:0.5ml 31
- 32. Cont. Need: • Where itis not possible to obtain satisfactory anesthesia of an exposed vital pulp or the child does not accept local anesthesia readily. • Where, following amputation of the coronal pulp, the radicular stumps continue to bleed excessively. • When the time factor or lack of cooperation from the child make it difficult to complete a single-visit pulpotomy procedure. • When an exposure is encountered at the end of a long visit on a young child, who is becoming restless 32
- 33. Technique First visit Place devitalizingpaste over the exposed site Fill the cavity for 7-10 days Second visit Rest of the procedure same 33
- 34. Beechwood creosote For Non-vitalPulpotomy or Two-visit Disinfection Pulpotomy or Mortal Pulpotomy Success rate about 66% 34
- 35. Cont. Creosote is acategory of carbonaceous chemicals formed by the distillation of various tars and pyrolysis of plant-derived material, such as wood or fossil fuel. They are typically used as preservatives or antiseptics.[ 35
- 36. Cont. Indications: • Inability toarrest haemorrhage from the amputated pulp stumps during a single- visit formocresol pulpotomy. • Pus at the exposure site or in the coronal pulp chamber. • Non-vital coronal and/or radicular pulp. 36
- 37. Technique of Non-vitalPulpotomy First visit Open pulp chamber &remove infected coronal pulp Irrigate the chamber Place cotton pellet moistened with Beechwood creosote in the chamber Seal for 7-10 days Second visit Open the tooth (symptomless) Remove the cotton pellet Place zinc-oxide eugenol paste over the floor of the pulp chamber Give cement lining Restore the tooth 37
- 38. Safety concerns • TheInternational Agency for Research on Cancer (IARC) has determined that coal tar is carcinogenic to humans and that creosote is probably carcinogenic to humans. • More toxic than formocresol. 38
- 39. Mineral trioxide aggregate(MTA) • Developed by Mahmoud Tourabinejad 39
- 40. Composition • Tricalcium silicate(CaO)3.SiO2 • Dicalcium silicate (CaO)2.SiO2 • Tricalcium aluminate (CaO)3.Al2O3 • Tetracalcium aluminoferrite • (CaO)4.Al2O3.Fe2O3 • Gypsum CaSO4 · 2 H2O • Bismuth oxide Bi2O3 40
- 41. Technique Open pulp chamber&remove infected coronal pulp Disinfection of the pulp chamber with 3%–5% sodium hypochlorite (NaOCl) Dry and control hemorrhage with wet cotton pellet Pressing the MTA to the walls and floor of the pulp chamber with a cotton wool pellet moistened in sterile water Final restoration 41
- 42. Drawbacks • Tooth discoloration •Chair side mixing and handling • High material cost 42
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- 44. CONT. • The bismuthoxide in MTA is replaced with tantalum oxide in NeoMTAPlus • Rest of constituents are same 44
- 45. CONT. • Designed forpaediatric use • Non staining • Wash-out resistant • Fast setting • Low cost • Powder and gel mixing to get final slurry paste • Final restoration may be of any material 45
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- 47. Calcium hydroxide • AlkalinePH • Bioactive medicament with good antibacterial properties by lowering PH. • Powder is mixed with normal saline. • Causes fixation of pulp tissues to depth of 2 mm and also remineralization • Used as a lining material ,dressing material, in pulp capping etc 47
- 48. Cont. • Its usein pulpotomy is now stopped because of its cytotoxic nature in deciduous teeth • Causes internal root resorption in deciduous teeth. 48
- 49. summary • The mostwidely used ever formocresol is now in phase of replacement • Study conducted at PIMS ,Islamabad, demonstrated that MTA has also a comparable clinical and radiographic success rate to that of formocresol. • Ferric sulphate is good alternative having same results at a reasonable cost too. 49
- 50. References • Alsanouni M,BawazirOA.A randomized clinical trial of NeoMTAPlus in primary molar pulpotomies. Pediatr Dent 2019;41(2):107-11. • Mutluay M, Arıkan V Sarı S,Kısa Ü. Does Achievement of Hemostasis After Pulp Exposure Provide an Accurate Assessment of Pulp Inflammation?Pediatr Dent.2018 Jan 1;40(1):37-42. • Milnes AR. Is formocresol obsolete? A fresh look at the evidence concerning safety issues. Pediatric Dentistry 2008;30(3):237–246. 50
- 51. • Paediatric operativedentistry fourth edition MEJ CURZON et all • Restorative technique in paediatric dentistry 2nd edition MARTIN DUNITZ • Intracanal medicaments in pediatric dentistry by shikar kumar and shrutti kumar • Pathways of pulp eleventh edition 51
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