Pulp Therapy in Children: Current Trends

Pulp Therapy in Children .ppt, powerpoint slide on pulp therapy

Outline

• Introduction
• Biology of the Pulp
• Rationale for Pulp Therapy
• Diagnosis
• Types of Pulp Therapy
• Current Trends
• Conclusion

Introduction

Over several decades, the emphasis in dentistry has shifted from the concept of a “doomed” organ that must be removed to one of organ recovery and health. Advances in pulp therapy have played an important role in this transition. No space-maintaining appliance can equal the natural primary tooth of the child during the development years.

Biology of the Pulp

The pulp contains:

• Blood vessels
• Lymph vessels
• Nerves
• A variety of cells:
  • Fibroblasts
  • Undifferentiated mesenchymal cells
  • Osteoclasts and odontoblasts
  • Defense cells: neutrophils, lymphocytes, macrophages

Characteristics of the Pulp

• Similar to connective tissue
• Tremendous healing potential; apical vascularization is important to the healing potential
• Coronal tissue is more cellular
• Apical tissue is more fibrous
• Pulp becomes more fibrotic with age

Functions of the Pulp

1. Induction: Pulp participates in the induction and development of odontoblasts which produce dentine, which in turn induces enamel formation.
2. Nutrition: Pulp supplies nutrients essential for dentine formation and hydration through dentinal tubules.

Functions of the Pulp (Cont’d)

3. Defense: Pulp can elicit an inflammatory or immunologic response to neutralize the invasion of dentine microorganisms and their by-products.
4. Sensation: Pulp transmits sensations via the nervous system, mediated through enamel or dentine to higher nerve centers.

Rationale for Pulp Therapy

The treatment of the dental pulp damaged by:

• Caries
• Accidental trauma during cavity preparation
• Tooth wear lesions
• Tooth fractures

This has long presented a challenge. As early as 1756, Pfaff reported placing a small piece of gold over a vital exposure to promote healing. The purpose of pulp therapy in Pediatric Dentistry is to maintain the health of the affected tooth and other oral tissues since no space-maintaining appliance can equal the natural primary tooth during developmental years.

The Functions of Primary Teeth Include:

• Aid in mastication
• Prevent possible speech problems
• Maintain esthetics
• Prevent aberrant tongue habits
• Prevent the psychological effects associated with early loss of teeth
• Maintain normal eruption time of succedaneous teeth
• Reduce the likelihood of tooth drifting and resultant malocclusion

Diagnostic Aids in the Selection of Teeth for Vital Pulp Therapy

The success of pulp therapy highly depends on making the correct diagnosis.

History Taking:

• Pain is usually the driving factor.
• Pain data includes nature, onset, spontaneity, severity, and duration.
• Absence of pain is not a reliable criterion; varying degrees of degeneration or complete necrosis can occur without pain.

Clinical Assessment:

• Inspection:
  • Hard tissue: presence of a large carious lesion, tooth color.
  • Soft tissue: signs of inflammation, such as a gingival abscess or a draining fistula associated with deep caries, indicating irreversibly diseased pulp.
• Percussion: May be used to detect apical pathology (use is controversial).
• Pulp Testing: Thermal test and mobility.
• Radiographs: Essential for diagnosing pulp disease in children.
  • Bite Wing: Shows involved surfaces and depth of the lesion in relation to the pulp.
  • Periapical: Shows furcation or apical involvement, calcified tissues, external root or bone resorption, and internal resorption.

Diagnosis

Reversible Pulpitis

• Not spontaneous
• Pain is of short duration and does not linger after stimulus removal.

Irreversible Pulpitis

• Pain is spontaneous and lasts for a few seconds to several hours after stimulus removal.

Apical Pathologies

• Pain is well-localized, and the tooth is tender to percussion.

Factors Considered Before Pulp Therapy

• Physical condition of the patient: In seriously ill children, extraction may be the treatment of choice after proper premedication with antibiotics.
• Level of parent and patient cooperation in treatment.
• Desire and motivation to maintain oral health and hygiene.
• Caries activity and overall prognosis of oral rehabilitation.
• Stage of dental development of the patient.

Objective and Principle of Pulp Therapy

The aim of pulp therapy is to seal the tooth off from the external environment using painless techniques, which necessitate anesthesia to gain the child's cooperation. The use of rubber dams is crucial, and infection control principles must always be followed.

Types of Pulp Therapy

Dental caries and traumatic injury are the main reasons for pulp therapy. The various forms of pulp therapy can be classified as:

Vital Pulp Therapy:

• Direct pulp capping
• Indirect pulp capping
• Pulpotomy (partial and complete)
• Apexogenesis

Non-Vital Pulp Therapy:

• Apexification
• Pulpectomy
• Root canal treatment

Indirect Pulp Capping

Definition: Placement of a dressing over residual hard carious dentine to allow secondary dentine formation within the pulp chamber.

Indications:

• Teeth with deep caries free from pulpitis
• No history of spontaneous toothache
• No tenderness to percussion
• No abnormal mobility
• No radiographic evidence of radicular disease

Contraindications:

• Teeth with deep caries and symptoms of pulpitis
• History of spontaneous pain
• Tenderness to percussion
• Abnormal mobility
• Radiographic evidence of inter-radicular bone loss or root resorption.

Materials for Indirect Pulp Capping

• Traditional materials: Calcium hydroxide, ZnO eugenol
• New materials: Composite resin and G.I.C. (use still controversial)
• Properties: Promote pulp tissue healing and minimize microleakage.

Procedure for Indirect Pulp Capping

1. Administer local anesthesia (LA) if uncomfortable.
2. Isolate with rubber dam.
3. Remove caries with a round bur or spoon excavator.
4. Leave a thin shell of carious dentine over the pulp.
5. Place a protective base over the dentine.
6. Temporize and leave for 6-8 weeks.
7. After the temporary dressing, remove remaining caries and restore the tooth.

Direct Pulp Capping

Definition: Involves applying a medicament to the exposed pulp to preserve its vitality.

Indications:

• Small pulpal exposures (pinpoint) that are iatrogenic
• Non-painful teeth
• Mechanical/traumatic exposure of the pulp in matured permanent teeth.

Contraindications:

• Primary teeth with carious pulpal exposure
• Teeth with excessive hemorrhage at the exposure site
• Teeth with periapical pathology
• Pulp calcification due to age or previous inflammatory responses
• Pulpal exposure >2mm in diameter.

An Historical Note

F. A. Hunter (1883) presented a formula for pulp capping involving sorghum molasses mixed with the droppings of the English sparrow.

Pulpotomy

A procedure in which the infected coronal pulp is amputated, with a medicament placed over the radicular pulp to maintain its vitality.

Indications:

• Carious exposure in asymptomatic vital deciduous teeth
• Traumatic or mechanical exposure of the coronal pulp of a primary tooth
• Immediate pain relief from acute pulpal pain in permanent posterior teeth.

Contraindications:

• Teeth with a very short expected lifespan
• Signs/symptoms suggesting inflammation beyond the coronal pulp.

Types of Pulpotomy:

• Vital
• Non-Vital
• Devitalization

Techniques for Vital Pulpotomy:

1. Anaesthetize and isolate with rubber dam.
2. Prepare access and remove coronal pulp.
3. Control bleeding with cotton pellets.
4. Apply medicament based on material used.

Non-Vital Pulpotomy

Also called mummification. This is a two-visit procedure indicated in young uncooperative children when pulpectomy is not feasible.

Indications:

• Very uncooperative patients
• Thick and discoloured (infected) serous fluid.

Contraindications:

• Periapical pathology and internal/external root resorption.

Pulpectomy

A procedure performed in primary teeth with clinical evidence of infection in both coronal and radicular pulp tissue.

Indications:

• History of spontaneous pain
• Presence of intraoral swelling or sinus.

Contraindications:

• A non-restorable tooth
• Pathologic root resorption.

Procedure:

1. Apply LA (optional).
2. Isolate with rubber dam and prepare access cavity.
3. Debride the pulp chamber and remove radicular pulp.

Current Trends in Pulp Therapy

Recent concerns have arisen regarding formocresol's implications as a pulpotomy medicament due to aldehyde toxicity, which has been reported for mutagenicity and carcinogenicity.

Alternatives to Formocresol:

• Ferric Sulfate: Brings less inflammation, not toxic, and bacteriostatic.
• Glutaraldehyde: Larger molecular size limits diffusion; less toxic than formocresol.
• Mineral Trioxide Aggregate (MTA): No mutagenic or cytotoxic properties; excellent success rates in pulpotomy cases.
• Bone Morphogenic Protein (BMP): Promotes osteogenesis and reparative dentin formation.
• Lasers and Electrosurgery: Provides alternative approaches without the systemic effects of traditional agents.

Conclusion

Preserving teeth that are pulpally involved may be time-consuming but is highly rewarding. Maintaining the dental arch and its functions supports mastication, aesthetics, speech, and prevents psychological issues associated with tooth loss in children. New materials and techniques are continually researched to replace formocresol, striving for reparative, regenerative, and biocompatible options.

References

1. Pitt Ford T.R; Endodontics in Clinical Practice; 2004; 5th Edition
2. Damle S.G. Paediatric Endodontics. In: Pediatric Dentistry; 3rd Edition. New Delhi, Arya, 2006; pp 336- 338.
3. International Agency for Research on Cancer. Press release no. 153. 15 June, 2004 [www document] URL http://www.iarc.fr/pageroot///prerelease/pr153a.html.
4. Zarzar P.A, Rosenblatt A, Takahashi CS, Takeuchi PL, Costa L.A. Formocresol mutagenicity following primary tooth pulp therapy: an in vivo study. J Dent 2003; 31: 479-485.
5. Andlaw R.J, Rock W.P. A Manual of Paediatric Dentistry, 1996; 4th Edition.