Saturday, August 20, 2011

Pulp Therapy in Pediatric Denistry


Definitions
Pulpotomy: Removal of coronal pulp and treatment of radicular pulp.
Pulpectomy: Removal of entire coronal and radicular pulp.
Principles of treatment Attempting to retain the vitality of the pulp in primary molars is not recommended because
(1) pulpal involvement is more likely,
 (2) it is difficult to accurately determine the likely condition of the pulp, and
(3) calcium hydroxide frequently leads to internal resorption. Therefore, direct pulp capping is only advisable for small traumatic exposures. Pulpotomy remains the treatment of choice for primary molars:

Pulpotomy techniques for vital pulps
In primary molars the relatively larger pulps result in earlier pulpal involvement; therefore, devitalization and fixation of the pulpal tissues gives more consistent results than techniques that attempt to retain vitality, e.g., indirect pulp capping. There are two alternative approaches:
  • one-visit formocresol pulpotomy; and
  • two-visit devitalization pulpotomy.
The choice of technique depends on the status of the pulp and cooperation of the child. The generally accepted pulpotomy treatment for primary molars is the one-visit formocresol pulpotomy.

One-visit formocresol pulpotomy
This method fixes most of the radicular pulp, but the apical part may be unaffected by the medicament.
  • Give local anesthetics and place rubber dam.
  • Complete cavity preparation and excavate caries.
  • Remove roof of pulp chamber.
  • Amputate coronal pulp with a large excavator or sterile round bur.
  • Wash chamber and arrest bleeding with damp cotton pellet.
  • Place cotton pellet dampened with formocresol on exposed pulp stumps for 5 min, then remove.
  • Apply dressing of reinforced ZOE cement.
  • Restore tooth, usually with a stainless steel crown.
Problems
Inadequate local anesthesia Repeat local anesthesia or use a two-visit technique.
Necrotic pulp Proceed with non-vital technique.
Profuse hemorrhage indicates more serious inflammation of the radicular pulp. Formocresol can be sealed in the canal for 1 week, then continue the procedure as above.
Alternative medicaments Ferric sulfate.

Two-visit devitalization pulpotomy
Sometimes there are occasions where it is not possible to obtain anesthesia of a vital pulp, or cooperation is difficult and a two-visit devitalization technique may be justified. Devitalizing paste is applied to the exposure on cotton pellet and sealed tightly in place for 2 weeks. On re-opening the pulp should be non-vital and treatment can proceed as for a non-vital tooth.

Non-vital pulp techniques
There are two methods used for treatment of the non-vital pulp.
Pulpotomy
This method removes infected coronal pulp and disinfects radicular pulp, thus allowing normal root resorption to proceed. It is still practiced in some centers, but carries a relatively low success rate (50%).
First visit
  • LA is required as part of pulp could still be vital.
  • Complete cavity preparation and removal of caries.
  • Remove roof of pulp chamber and excavate pulpal debris.
  • Place cotton pellet moistened with beechwood creosote or formocresol in pulp chamber.
  • Seal with temporary dressing (GI or zinc oxide-eugenol [ZOE]).
  • Arrange next appointment for 1-2 weeks later.
Second visit
  • Check for symptoms; if there are none, proceed.
  • Remove temporary dressing and cotton pellet.
  • Place antiseptic dressing (50:50 formocresol and eugenol mixed with zinc oxide powder) and press down into root canals.
  • Restore tooth.
Problems
Vital and/or sensitive tissue encountered Place devitalizing paste and seal for 1-2 weeks before proceeding with non-vital pulpotomy.
Abscess formation during treatment Either repeat (consider whether you need to incise abscess), carry out pulpectomy, or extract tooth.
Alternative medicaments Formocresol, and “Kri” liquid have been suggested.
Technique for abscessed teeth Acute abscesses require drainage to relieve symptoms. This can be achieved by either leaving the tooth on open drainage for 1 week before proceeding as above (this is more applicable to upper teeth) or incising the abscess under topical LA. Chronic abscess drainage may be occurring through a sinus; if so, proceed straight to firstvisit technique. If drainage is occurring through an occlusal cavity, placement of a seal may lead to exacerbation in symptoms; therefore, always warn parents to return if there are any problems.

Pulpectomy
A pulpectomy is often considered difficult in primary molars because of the complexity of ribbon-shaped canals (although instrumentation is often easier than some texts might suggest). The risk of damage to the permanent successor also needs to be considered, but if conditions are favorable it is the treatment of choice for non-vital pulps.The technique can be carried out in one or two visits.
  • Use LA and rubber dam.
  • Remove the necrotic pulp, locate and file canals.
  • A radiograph to show position of files is desirable but not essential.

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