Ped i-10

‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
1

College of Dentistry
Pedodontic I
Management of deep carious lesions in
children
Vital pulp therapy
Dr. Hazem El Ajrami
2

Pulp exposure is caused most commonly by
caries but may also occur during cavity
preparation or by fracture of the crown. Pulp
exposures caused by caries occur more
frequently in primary than in permanent teeth
because primary teeth have relatively large pulp
chambers, more prominent pulp horns and
thinner enamel and dentine. In primary molars
with proximal cavities, pulp involvement occurs
in about 85 % of those with broken marginal
ridges.
3

• Exposure of the pulp by caries is invariably
accompanied by infection of the pulp. The
infected pulp becomes inflamed and necrosis
may result. If infection spreads to the alveolar
bone, the developing permanent tooth may be
affected. For these reasons, a primary tooth
with a pulp exposure should not be left
untreated. When these carious exposures could
be treated with consistently good results,
several problems in dentistry would be solved.
The clinical condition of the carious tooth and
its surrounding tissues is an important
diagnostic factor.4

• Diagnostic aids in selection of teeth for vital
pulp therapy:
1. History of pain:
The history of either presence or absence of
pain may not be as reliable in the differential
diagnosis of the condition of the exposed
primary pulp as it is in permanent teeth but it
should be taken into consideration in selection
of the teeth for vital pulp therapy. Information
may be taken from the parents and history may
be helpful in determining the status of a
painful tooth.6

• The dentist should distinguish between two
types of pain: provoked and spontaneous pain
(unprovoked).
• Provoked pain is precipitated by stimulus
(thermal, chemical or mechanical irritants) and
disappear after removal of the stimulus, this
denotes that the pulp is vital and protected by a
thin layer of dentine and can be treated
successfully with good prognosis (e.g. pain after
hot or cold drink, pain immediately after eating).
7

• Spontaneous pain is a throbbing constant pain
that may keep the patient awake at night. It
indicates advanced pulp damage, which means
that involvement of the pulp has progressed
too far for treatment preserving pulp vitality or
with even a successful pulpotomy.
8

2. Clinical examination:
A careful intraoral examination is of extreme
importance in detecting the presence of a
pulpally involved tooth.
A. Tooth mobility:
Abnormal tooth mobility is a clinical sign
that may indicate a severely diseased pulp or
involvement of periodontal ligaments
(pathological mobility must be distinguished
from normal mobility in primary teeth near
exfoliation).
9

B. Sensitivity to percussion:
Percussion should start with a very gentle
and careful tap by the tip of the finger to
prevent exposing the child to uncomfortable
stimuli. If the tooth is sensitive to percussion,
this indicates' apical or pulpal inflammation or
both.
C. Examination of mucobuccal fold:
Presence of swelling, sinus, draining fistula
or chronic abscess associated with a deep
carious lesion is a sign of an irreversibly
diseased pulp (non vital pulp).10

D. Size of exposure and amount of pulpal
bleeding:
Size of exposure, appearance of the pulp and
amount of bleeding are the most valuable
observation in diagnosing the condition of the
primary pulp. The most favorable condition for
vital pulp therapy is the small pinpoint
exposure surrounded by sound dentine. If the
exposure is large and associated with watery
exudate or pus, the tooth is not suitable for
vital pulp therapy.12

3. Radiographic interpretation:
The clinical examination should be followed
by a high quality periapical and bite-wing
radiograph to examine periapical area and
supporting bone. Pulp exposure cannot be
accurately detected from an xray film.
13

• Radiographic interpretation in children is more
difficult than adults due to:
 Young permanent teeth with incompletely
formed root ends giving the impression of
periapical radiolucency.
 The roots of primary molars undergoing
normal physiologic resorption often present
a misleading picture or one suggestive of
pathologic change.
 Permanent teeth are superimposed on the
primary teeth.
14

• Radiographs are valuable for determining the
following:
Periapical changes such as thickening or
widening of periodontal membrane space.
Rarefaction in supporting bone.
Presence of calcified masses within the pulp
chamber and root canals.
Periapical and interradicular radiolucencies of
bone.
16

4. Vitality tests:
 The vitality tests are not reliable in the child
dental patient in diagnosing a deep carious
lesion but it should be taken into
consideration. It gives an indication of
whether the pulp is vital but it does not give
reliable evidence about the extent of the pulp
disease.
 Pulp vitality tests may be used either thermal
or electrical.
17

• Thermal pulp vitality test:
The thermal test includes the application of
heat (hot gutta percha or hot instrument) or cold
(ethyl chloride or ice cone). The reaction of a
normal tooth with vital pulp is tested first
(Normal response: pain on application of hot or
cold stimulus, which disappears after removal of
the stimulus). If the pain persists, this indicates
pulpitis. If the pulp does not respond to thermal
stimuli, (the child does not feel any pain) this is
an indication of non vital pulp.
18

• Electric pulp tester:
It is an apparatus used to test pulp vitality.
Record the reading of a normal tooth with vital
pulp first, then record the reading of the
carious one. If the pulp of the affected tooth
responds at lower reading than normal this
denotes hyperemia or pulpitis. If it responds at
a higher reading than normal this is an
indication of pulp degeneration.
19

• Disadvantages of electric pulp tester:
Electric irritation to the pulp.
False positive result when content of pulp is
liquid in case of liquefaction necrosis (the
pulp is non vital although it responds at a
lower degree).
The child might be apprehensive and the
dentist lose child's confidence causing
disruptive behavior.
20

5. Physical condition of the patient:
Successful pulp therapy is dependent in
some measures at least upon the absence of
systemic disturbance that might exert a
deleterious effect on the pulp. Seriously ill
children, suffering from heart disease, nephritis,
leukemia, tumors, cyclic neutropenia should
not be subjected to the possibility of acute
infection resulting from pulp therapy aside
from the fact that pulp might not possess
normal regeneration power. Extraction of the
involved tooth after proper premedication with
antibiotics is the treatment of choice in such
serious diseases.21

I. Indirect pulp capping.
II. Direct pulp capping.
III. Pulpotomy.
IV. Partial pulpectomy.
V. Complete pulpectomy (endodontic treatment).
Vital pulp therapy
23

 Pulp capping:
The aim of pulp capping is to maintain pulp
vitality 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).
24

I. Indirect pulp capping:
 Indications:
Indirect pulp capping is used when the tooth
has a deep carious lesion in which case the
total removal of all carious dentine would most
certainly result in large pulp exposure
necessitating complex and expensive
treatment. This procedure may be considered
successful provided that there is no root
resorption and absence of mobility or
periapical inflammation radiographically.25

 Procedure:
 First visit:
1. Without local anesthesia nor rubber dam
application, excavation of the superficial layer
of caries is done up to the last thin leathery
dentine layer.
26

2. The remaining carious dentine is dried (the
capping material will not adhere on wet
surface) and a layer of zinc oxideeugenol is
applied on the dentine surface. Zinc oxide-
eugenol is a germicidal agent which kills
bacteria present in carious lesions and prevent
progression of caries toward the pulp i.e. arrests
carious process. This gives the chance to the
pulp for healing and regeneration.
27

3. The overhanging walls of enamel should be
left as such because it provides retention for
the dressing.
4. The cavity is filled with zinc phosphate
cement or fortified zinc oxideeugenol and
left as such for 6-8 weeks.
28

• Treatment can be judged successful if:
 The restoration was intact.
 The tooth was not sensitive to percussion.
 No history of pain after treatment.
 No radiographic evidence of radicular
diseases.
 No radiographic evidence of root
resorption.
 No clinical evidence of direct pulp exposure
when the tooth was reentered and the
residual carious dentine was examined or
excavated.29

 Second visit: 6-8 weeks
During the waiting period, the caries process
in the deep layer will become arrested and soft
caries is hardened. A protective layer of
reparative dentine has been formed.
A. The tooth is anesthetized and isolated with
rubber dam.
B. Carefully remove remaining carious dentine,
which is somewhat hardened and the cavity
preparation is completed in the conventional
manner and the tooth is restored as usual.
30

II. Direct pulp capping:
 Definition:
Direct pulp capping is the procedure of
covering the exposed vital pulp by a material,
which promote healing of the vital pulp
tissues.
32

 Indications:
1. They should be limited to traumatic exposure
(during cavity preparation).
2. Small pinpoint exposure surrounded by sound
dentine.
3. Recent exposure.
4. Vital pulp free from infections.
5. No bleeding at the exposure site or an amount
that would be considered normal (No
hyperemia or inflammation).
6. Normal radiographic findings.
33

 Technique:
1. If traumatic exposure occurs during cavity
preparation, the tooth previously anaesthetized
and isolated with rubber dam or cotton rolls.
2. When a pulp is exposed during the last stages
of caries removal, carious dentine chips will be
pushed into the pulp tissue. These dentine chips
and fragments in exposed pulp after capping
induce foreign body reaction. The necrotic
material introduced with numerous small chips
of contaminated dentine can result in pulpitis or
abscess.
34

3. Enlarging the exposure site:
Enlarging the opening into the pulp tissue
are needed for the following reasons:
A. Allow carious and non-carious fragments
to be easily washed away.
B. Facilitates direct contact of capping
material with pulp tissues.
35

• Only non-irritating solution such as normal
saline or chloramine T should be used to cleanse
the area, to flush the exposure free of debris and
keep the pulp moist while the blood clot is
forming before the placement of the capping
material.
• Calcium hydroxide is the material of choice of
capping exposed vital pulp tissue, zinc oxide-
eugenol is placed over the calcium hydroxide
layer as a sealant then zinc phosphate cement
and the permanent restoration is inserted at the
same appointment.
36

• Direct pulp capping is not encouraging in
primary dentition. The success of pulp capping
depends upon the presence of young, active
undifferentiated mesenchymal cells, which can
be induced to transform into odontoblasts. In
primary dentition, pulp tissue ages early and
less cellular elements are available. Moreover,
some cells may transform to odontoclasts
causing internal resorption.
37

III. Pulpotomy:
 Definition:
It is removal of the coronal pulp tissues
until the level of entrance of the pulp canals
and capping the radicular pulp tissues to
keep it in good condition.
39

 Indications:
1. It is used in primary and young permanent
teeth with vital exposed pulps when the
tissues adjacent to exposure site show slight
evidence of inflammation.
2. Slight amount of bleeding at the exposure
site considered within normal.
3. Wide old exposure.
4. Normal clinical and radiographic signs.
41

 Technique:
1. Anesthetize and isolate the tooth with rubber
dam.
2. Obtain outline form to ensure access to the pulp
chamber.
3. Removal of all carious material with round bur
and spoon excavator, this ensure a clean
operating field.
4. Remove the roof of pulp chamber using a sterile
fissure bur in a low speed hand piece. Insert it
into the exposure site and move it mesially and
distally as required to remove the roof of the
pulp chamber.
42

5. Remove any overhanging ledges of dentine,
pulp tissues under ledges may not be easy to
remove.
6. Excavate the coronal pulp with a large spoon
excavator or with round bur (when bur is used
care must be taken not to perforate the floor of
pulp chamber).
7. Wash and flush the pulp chamber with sterile
water or saline solution. This washes away the
debris and pulp remnants from the pulp
chamber.
43

8. Dry and control bleeding with sterile cotton
pellets for about 4 minutes. If bleeding
continues, look for remnants of coronal pulp
still adhering to the walls of the pulp chamber
and remove them.
9. According to the capping material used we are
going to call the procedure either calcium
hydroxide or formocresol pulpotomy.
45

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