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Pediatrics VIVA revision:

Pulpotomy: Removal of the coronal pulp thas is affected or infected (non-vital),


whilst preserving the vitality and function of the remaining
radicular pulp.

Indications:
- Individual tooth factors:
- Large carious lesion – substantial loss of normal tooth anatomy
 A lesion that is sitting in or on the pulp
 Extensive loss of tooth structure
**good indication is a substantial loss of the marginal ridge in a
primary tooth**
- Vital pulp:
o Reversible pulpitis symptoms – pain for short duration, no
swellings
o Must be absence of swelling/tenderness/pus/ mobility/pain
- Dental factors:
o Large carious lesion with substantial loss of the marginal ridge
 Large carious lesion nearing the pulp
o Relatively intact dentition
o Lack of permanent successor
o Minimal root resoption
- Patient factors:
o Compliant child and family

Contraindications:
- OPPOSITE OF INDICATIONS… Neglected dentition, poor compliance
- Individual tooth factors:
o Evidence of irreversible pulpitis / necrosis (hx of spontanout pain)
 No bleeding from the pulp (necrotic)
 Hyperaemic pulp – excessive bleeding
o Mobility
 Tooth close to exfoliation
o Radiographically:
 Periapical pathosis
 Internal root resoption
 Radicular bone loss
 Pulp calcification
- Dental factors:
o Unrestorable crown
o Inability to place rubber dam
Materials in pulpotomy:

Irrigants,,,
Formocresol:
 Intention is Devitlisation of the coronal aspect (destroy coronal pulp)
 Bactericidal and devitalizing properties
 High success rate (higher success rate than ferric suplphate)
o Very effective, but no longer used due to cancer risk

Ferric sulphate:
 Intention of retention of maximal vital tissue without
induringformation of reparative dentine
 Has a homeostatic effect causing the coagulation of the blood,
stopping the bleeding

Calcium hydroxide:
 Intention of formation of reparative dentine
o Stimulates underlying odontoblasts to lay down dentine
 Not overly effective (60%)
 Antibacterial activity

MTA – Mineral trioxide cement


 Acts literally as a cement in the mouth
 Very high success rate, but lacking the statistical support at the moment
 Very expensive
The process

1) Pre operative radiograph

2) Placement of rubber dam, removal of caries

3) Caries has progressed through into and involving the


pulp

4) Caries pulp exposure – removal of the caries

5) Exposure of all coronal pulp – expanding the


preparation of to expose the pulpal horns

6) Continued removal of the pulp to the floor is reaches

7) Irrigate the pulp chamber to remove debris

8) Ferric sulfate placement and left for 15-20 seconds to


control haemorrhaging

9) Irrigate gently the pulp chamber to remove debris

10) Cement placement into the cavity as a capping (ZOE)

11) Placement of GIC over the ZOE

12)Cutting back of the GIC allowing for placement of a


stainless steal crown
Pulpectomy

The removal of as much necrotic and infected pulp as possible, including pulp in
the root canals
…to fill them with a suitable material in order to preserve the
tooth, and allow for physiological root resoption

Completed on a non vital tooth (?? – irreversible pulpitis??)

Outcome – often very unpredictable

Indications
- Tooth with irreversible pulpitis or necrotic pulp tissue
o …the contraindications for a pulpotomy
o Persistent bleeding during pulpotomy (only seen when complting
pulpotomy)
- Lack of permanent successor

Contraindications
- Periradicular involvement extending into the permanent tooth bud
- Root resorption of more than 1/3 or the root (exfoliation)
- Excessive internal root resoption
- Caries perforating the floor of the pulp chamber

The process:
- La and rubber dam
- Remove necrotic pulp
o Locate, instrument and irrigate canals (NaOCl)
o Clean to within 2-3mm of the expex
- Fill canal with plain ZOE or non-setting calcium hydroxide
- Restore with SSC
Stainless steal crowns: The gold standard for primary restorations
…Indications with gross caries, coronal destruction, pulp therapy

Advantages:
- Durable (>3 years)
- Longer clinical lifespan than 2/3 surface CR or amagam restoration

Disadvantages:
- Const
- Requirement of LA in placement
- Aesthetics poor
- Can be difficult to fit – especially with space loss

Indications:
 Extensive caries
 Following pulp therapy (pulpotomy or pulpectomy)
 Malformed / hyperplastic or hypomineralise teeth
 Severe bruxism (extensive tooth wear

Contraindications:
 Poor aesthetics
 Teeth close to exfoliation (within 12-26 months) – overservising of
primary teeth
o Option of extraction and placement of space maintainer (placed if
exfoliation is more than 3 months off)
 Inadequate tooth structure
 Evidence of a non-vital pulp (without pulp therapy being completed)

Reasons for failure:


- Poor preparation / adaptioanio / rentetion
- Inproper cementation
- Pailure of pulp therapy
- Recurrent caries

Technique for placement:


(1) – LA and placement of rubber dam (if possible)
(2) – Selection of crown size – measured in relation to M-D length
(3) – Removal of caries
(4) – Occlusal reduction of ±1mm
(5) – Proximal reduction (20 degrees?)
(6) – Placement of the crown with a ‘clicking fit’
(7) – Assess the height and occlusion
(8) – Crimp edges
(9) – Place GIC into crown and place crown
…remove excess GIC from the margins of the crown
Halls technique:
Use of a SSC for sealing decay in a deciduous molar and management of
hypomineralised teeth

Involved the cementing of the crown with GIC, without completion of any cavity
preparation/caries removal (negating the need for LA)

Aim – to isolate carious lesions from the oral enviorment,


plaque, alteration of bacteria to become less cariougenic
 slowing/stopping caries progression

Indications:
- Proximal lesions, cavitated and non-cavitated
o Small to moderate
- Occlusal carious lesions, cavitated and non-cavitated
- Radiographically – lesions not extending beyond the middle 1/3 of
dentine (see a clear band of dentine between pulp and lesion)

Contraindications:
- Caries that extends beyonf the middle 1/3 of dentine radiographically
- Signs and syptoms of irriverisble pulpitis
- Heavily brocken down tooth (deemed unrestorable with conventional
restorations)

Technique:
- Place separators interproximal a few days prior to placing the crown
- Check that the carious lesion is free from PA pathosis and pulpal pathosis
- Select the crown size, fill with a suitable (1 size above that indicated from
size chart of M-D length)
- Trial the crown to ensure tight ‘snapping fit’
- Fill with a suitable material (GIC) and place on the tooth
- Have the pt bite down
- Clear away excess cement
- Occlusion will even out within a few weeks
The 4 D’s……

Fluorosis Mottling of the tooth enamel from excessive ingestion of fluoride


whilst the teeth are developing in the maturation stage

Clinically:
- More generalized (as opposed to hypomineralisation – occurring on
molars and incisors)
- In its mildest form – fluorosis is a form of hypomineralisation
- Fluorosis manifests as the mottling of enamel – ranging from white flecks
to confluent opacities throughout enamel (with pitting and discoloration)

(higher concentrations of fluoride severe may possibly be


hypolplasia)

Management:
Severely affected cases may require: either in a localized or a more generalized
manner, or porcelain veneers.
- Microabrasion – used with caution (potentially destructive to soft and
hard tissues)
o Use of 14% HCl acid (with or without pumice)
 Rubber dam always used
 Slowly rotating rubber cup for 10 seconds, rinse thoroughly
with water and assess (completed a maximum of 10 times)
o Alternatives – pumice and etch,
- Polishing surface with polishing burs
- Application of CPPACP after treatment with NaOCl
- Restoration with composite resin, veneers
-

http://www.thed3group.org/the-basics.html
Enamel Hypoplasia = developmental deficiency in the thickness of enamel
- Disturbances in the matrix formation
- Characterized by thin/pitting/grooved enamel
- High concentrations of fluoride may possibly cause hypoplasia

Management:
- Restoration with CR
- Possible SSC for grosly effected teeth
- Realisitic assessment of the prognosis of 1st molars – orthodontic referral
if extraction required.
- Onlays, veneers, crowns – delayed until late adolescence

Hypomineralisation = refers to a deficit in its mineral content


- Disturbances of the calcification of teeth
- Possible causes – repeated dosages of antibiotics when young,
- Appearance with a colour change – white/yellow/brown/opaque
- Characteristic – relatively fast rate of change post eruptively
- Affected enamel = weak and prone to breakdown
o Usually effecting incisors and molars
o ^^Molar incisor hypomineralisation
 Change in enamel quality - ranging from localized opacity
through opacity with discoloration and obvious poor
quality to enamel loss, probably due to post-eruptive
breakdown.
 Affected 6s have hypomineralisasion of enamel,varying
from discoloration to severe enamel dyplasia
 Post eruptive breakdown may be evident – (more caries,
and sensitivity)
 Yellow/white radiopcities
 Management:
 Ideal restoration is unknown:
 Possibly SSC

- Causes: prolonged labour, fluoride, congenital heart diease, butritiona,


hereditary

Treatment of hypomineralisaion / hypoplasia:


 Depends on the extent and severity:
o Areas of hypoplasia – can be fissue sealed/restored conventionally
o More severe = crowning, possibly SSC as semi permentnet in children
 MIH – possible SSC placement, or coronal restoration, or extraction

Ameologenesis imperfecta

- Inherited defects of the enamel of both primary and permanent teeth (but
not always congenital aetiology).
- Many classifications – but generally classified by the type of enamel
deficit and the mode of inheritance
o Hypoplastic – enamel thin, or pitted
o Hypocalcified – enamel is dull, no shine, opaque white/honey/
brown
o Hypomaturation – mottled/frosty looking white, opacities,
condfined to coronal 1/3 of tooth (snow capped)
- Usually both primary and secondary dentition are effected

- Clinical features:
o Thin enamel.
o Lack of contact points between teeth.
o Enamel may be rough, smooth, or randomly pitted.

Thickness deficit in Hypoplasia traces


back to an early error during secretion of
the developing enamel layer – and as a
result, enamel Hypoplasias are always
present before a tooth first enters the
mouth. In contrast, the mineral deficit in
Hypomin enamel happens later in
development, after the enamel layer has
been secreted – so Hypomin defects
involve enamel of normal thickness, in
unerupted teeth at least.

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