Pulp therapy guideline Value of each involved teeth to

overall develpment of child

Pulp therapy
Alternative to pulp treatment
Maintain integrity and health of the teeth
and supporting tissues Resotrability of the tooth

Treatment objective is to maintain the If infectionus process cannot be arrested

vitality of the pulp of affected teeth in -> extraction
young permanent teeth
Always use dental dam -> minimize
Indications, objective and type of pulpal contamination and maximize isolation
therapy depends on
Take bite wing and PA immediately after
Whether the pulp is vital or non-vital the procedure to document the quality of
(symptom free and normal response to the work
vitality testing)
Re-evalate 6 and 12 months after
Nver do hot testing on infected teeth
Apply protective liner
Cold test only for closed apices
Cover dentinal tubules
Reversible pulpitis
Minimize injury to pulp
Symptomatic or asymptomatic irrversible
pulpitis Promote pulp tissue

Clinical diagnosis via Minimize post op sensitivity

Placed in deep areas of prep to preserve

tooth vitality

Indirect pulp therapy

Deep carious lesion

Caries is left to avoid pulp expsure

Coverd with bio-compatible material (GI,

RMGI)

If using CaOH, cover it with GI

For permanent teeth, electric pulp and Good prognosis if the carie is well sealed
thermal test may be helpful
Indicated for primary teeth with no
Irreversible pulpitis or necrosis => pulpitis or Rev Pulp
candidate for pulp treatment
For open apices
Sinus tract
Sealing is key
Spontaneous toothache
Contraindication
Excessive mobility without trauma or
exfoliation Pulpal exposure

Frucation/apical radiolucency Spontaneous pain

Reversible pulpitis Fistula

Shor tooth pain, alleved with Indication

analgesic, brushing Viral pulp with no vlincial or
Candidate for vital pulp therapy radiographic pathology

Recommendations Small mechanical exposure of pulp

First consider Traumatic exposure of the pulp due

to tooth fracture
Patient medical history
 Direct pulp cap Bleeding at first (means vital) but after
treatment, no bleeding should be present
Exposure of pulp during cavity prep or
trauma Most effective restoration is Stainless
Steel Crown
Place MTA or calcium hydroxide

Direct pulp capping is not recommended

for primary teeth Non vital pulp tx

SIDE NOTE Pulpectomy

Root canal procedure for irreversibly

infected or necrotic
go down as far down the canal until it doesn't
bleed-> to allow growth Root canals= debrided, disinfected with
sodium hyperchlorite
4 mm diamond bur, go half length of bur,
carbide with copious water, wait 1 min and if Root must be minimally resorbed to do
it doesn't bleed (control bleeding with cotton this
pellet) then it means no more infection
Symptoms should resolve within few
use glass ionomer and MTA weeks

indirect plp cap with silver dianamide fluoride There should be no pathologic root
treatment resorption or furcation/apical
radiolucency

On a young permanent teeths

Indirect pulp

Remove out side caries along DEJ

They lay down liner to close

2nd step= remove rest of the caries over the

pulp arrested by liner

Direc pulp cap

Small exposure of the pulp during cavity prep

Cap with MTA or calcium hydroxide

Permanent tooth

Nonvital pulp treatment of primary teeth w/

irreversible pulpitis or necrotic Partial pulpotomy

If slight into pulp,

Pulpotomy Control the bleeding via chlorahexidine

Extensive caries in primary teeth but MTA

without radicular pathology Then light cured RMGI or GI
Coronal pup is amputated and remaining
vital radicular pulp is treated with
Bucklyes soltion of formocresol Partial pulpotomy with traumatic exposure

MTA can also be used, MTA performs Inflammed pulp tissue

equal to or better than formocresol
Control the bleeding- sodium hypochlorite or
chlorohexidien
 MTA

Light cured RMGI

On an incompletely formed apex

Nonvital pulp

Pulpectomy

On apexified permanent teeth

Remobe entire roof of pulp chamber to

gain access to canal and eliminate all
coronal pulp tissue

Soft tissue eval

Perform these procedures on pts

 If

Then indirect pulp cap is contraindicated

Goal

IPC

Direct pulp cap

-> use a smart bur = cuts only infected dentin => Never do a direct pulp cap on a primary
Indicated by dentition

Use GI liners
 tooth is non-vital if there is no bleeding when
entering the chamver

-> immunosppressed children, if the infection is

not deep = try to save

-> but if deep pulponomy or pulpectomy => take

the tooth out

if you see bleeding = still some vital tissue with

85-90% success rate

radiographs must show intact tooth structure

key is to remove the infection -> then any
medicament used doesnot make a difference
Formocresol- may cause cancer

remove and open up with 330 bur around the

edge and center is left(flies off) then stop using
high speed to protect bifurcation
Formocresol is left in their for 5 min

ZOE- strong, acrylic fiber,

=> don't want it any deep in the root because of

permanent teeth wont be able to resorb

other restorations = margins deteriorate bt

stainless crown, less repair

use 4 or 6 round bur to remove any ledge->

necrotic pulp tissue may get stuck

use a 2 round bur 1mm to 1.5 mm

the put cotton pellet

 pain from pressure on necrotic tooth

puss released through fistula/sinus tract

extract tooth for child witht celllitis

mechanicallly remove and chemically remove

with sodim hypochlorite

no bleeding, smell gunky, puss -> necrotic tooth

remove and sterilize tisses = sodium hypochlorite

pulpotomy - medicated paid for

pulpotomy - medicated paid for

When extracting, can section tooth

Complication
Local anesthetics for child

The injection procedure produces the

greatest negative response in children

Prevention of pain can nurture trust, allay

fear and anxiety and promote a positive
dental attitude

Patient Assessment

Know your patient

Medical History

(Allergies, Medications, ER/Hospitalizations)

Dental History

Previous experience
 Is patient in pain? Tissue acidity Is increased

Ability to cooperate Inhibits anesthetic action

Anxiety level Needle should not be inserted in area of
active infection
Treatment (Invasiveness, Complexity)

ADverse rxn to local anesthetic

Local Anesthetics -
Within 5-10 min of injection
Criteria for use:

Be nonirritating Psychogenic

Produce minimal toxicity Syncope

Be of rapid onset Allergic

Provide profound anesthesia Tre allergy to amide anesthetic is

extremely rare
Be of sufficient duration

Be completely reversible

Be sterile

Actions and Properties of Local Anesthetics

Penetration of nerve cell membrane to block If allergic to bisulfites, use LA without

influx of sodium ions = road block vasoconstrictor

Temporarily blocks the normal generation Pts with sulfa allergy

and conduction of action potentials to
prevents membrane depolarization Dont get articaine

Produce loss of sensation to pain in a Aboid benzocaine topical anesthetic

specific area of the body without the loss of Toxic
consciousness

Vaso constrictor

Decrease the blood flow in the immediate

area

Higher concentration = longer duration

of local anesthetic agent

Absorption of anesthetic agent into

bloodstream is ths slowed

Decrease bleeding of surgical area Idiosyncratic

Lipid solubility If LA gets into CNS,

Increase speed of onset Biphasic rxn

Increase penetration-> increasead potency Early: dizziness, anxiety and confusion

Increased duration Later depression: diplopia, tinnitus,

drowsiness

Objective sign
If infection is present
Muscle twitch, tremor, shiver, seizure
 Biphasic response

Initially

Increased HR, BP

Later

Depression

Decreased HR

Cardiac depressant effects are not seen

until there is a significantly elevated local
anesthetic blood level

POSTERIOR RESTORATIONS IN PEDIATRIC

DENTISTRY

PRIMARY POSTERIOR MORPHOLOGY

McDonald, Avery- Chapter 4

Crowns of primary teeth wider M-D, than

permanent successors

Buccal and Lingual surfaces of primary

molars are flatter above the cervical
curvature

Primary teeth are lighter in color

Max primary 2nd molars have an oblique

ridge just like the permanent max 1st
molars.

Mandibular 1st molars also have this

transverse ridge
 Primary teeth have broad contacts, making a
interproximal contact challenging at times

Initial prep .5mm into dentin

Enamel is 1mm deep

Extend preps to include all carious and

retentive pits/fissures

Round pulpal line angle

Reduce concentration of stress

Walls converge with the greatest width

at the pulpal floor

Ideal isthmus form no more than 1/3rd

the intercuspal distance

Class II material: amalgam, compomer?

Class I: amalgam, composite, GI, compomer

Class V: composite, GI

Development and Morphology of

Primary Teeth!
Stainless steel crown