BDS 7133 Management of Deep Carious Lesions in Children PDF

BDS 7133 Management of deep carious lesions in children (pulp therapy in primary teeth) 1 Aim: To describe the techniques to manage vital, pulpally involved primary teeth. Objectives: Subject Title Goes Here • Describe the pulpal morphology of primary teeth • Explain the signs and symptoms of irr...

BDS 7133 Management of deep carious lesions in children (pulp therapy in primary teeth) 1 Aim: To describe the techniques to manage vital, pulpally involved primary teeth. Objectives: Subject Title Goes Here • Describe the pulpal morphology of primary teeth • Explain the signs and symptoms of irreversible pulpitis in children • Evaluate different methods for managing the vital pulp of the primary molar and apply them where appropriate Introduction: • The principal goals of paediatric operative dentistry are to prevent the extension of dental disease and to restore damaged teeth to healthy function. To this end, a range of endodontic procedures provide an alternative to extraction for many pulpally compromised primary teeth. Introduction: • Pulp exposures caused by caries affect primary teeth more frequently than permanent teeth as primary teeth have a relatively large pulp chambers, more prominent pulp horns and thinner enamel and dentine. • Pulp exposure is most commonly caused by caries but may also occur during cavity preparation or by fracture of the crown. Introduction: • The first treatment decision for the young patient with one or more extensively carious primary molars is whether to retain or extract these teeth. Any treatment plan should be based on a thorough history, examination and appropriate investigations. It should also take into account the patient’s social, medical and dental status. Pulp in primary teeth: While many of the general principles and operative procedures in the primary dentition are shared with adult endodontics, a number of important differences between primary and permanent teeth which justify the special coverage: • The pulp outline follows the dentino-enamel junction more closely in primary teeth than the permanent. • Pulp horns are higher in the primary molars especially the mesial pulp horn. • Pulp chambers are relatively larger in primary teeth than the permanent teeth. Pulp in primary teeth: • The root canals of primary molars have more lateral branching and apical ramifications than permanent molars. • Apical formania in primary teeth are relatively wider than the permanent teeth. Assessment of pulpal health: • The assessment of the pulp requires a careful history and a thorough clinical and radiographic examination. This information will help clinicians to identify the probable extent of any pulpal inflammation and how reversible it will be. • It is often difficult to assess the pulpal health as many clinical or radiographic signs may only appear once the tooth is infected. • Studies in the early 1970s showed that in over 50% of primary molars where loss of the marginal ridge had occurred, pulp inflammation was irreversible. More recent work (Duggal et al. 2002), has shown that most teeth had pulp inflammation involving the pulp horn adjacent to the proximal carious lesion even when caries involved less than half the marginal ridge. Chances of pulp exposure: ✓Primary  permanent teeth Incase of broken marginal ridges Assessment of pulpal health: • There are a number of different treatment options for carious primary teeth with an inflamed pulp. For these to be successful, all clinical and radiographic findings must be collected and evaluated to ensure that the most appropriate treatment option is chosen. • As the diagnosis of inflamed pulp is not an exact science, there are certain patients for whom the consequences of a misdiagnosis and resulting infection are not worth the risk of retaining the tooth. • Consequently, unless all caries has been removed and there is still a good depth of dentine left, the tooth is extracted. These patients include those at risk of endocarditis and those who are immunocompromised (e.g. during treatment for leukaemia). Diagnosis of primary teeth is derived from: A comprehensive medical history: ( seriously ill children ex: heart disease, leukemia , nephritis or tumors should not be subjected to the possibility of infection due to pulp therapy). A review of past and present dental history A subjective evaluation of the area associated with the by questioning the child and parent current symptoms/chief complaint on the location, intensity, duration, stimulus, relief, and spontaneity. An objective extraoral examination as well as examination of the intraoral soft and hard tissues. If obtainable, radiograph(s) to diagnose pulpitis or necrosis showing the involved tooth, furcation, periapical area, and the surrounding bone. Clinical tests such as palpation, percussion and mobility. • Treatment prognosis can be determined by: I.History of pain: Pain can be provoked or spontaneous. • Provoked pain (good prognosis): Pain precipitated by a stimulus; pain on eating due to pressure of accumulated food that causes chemical irritation in the carious lesion or pain due to cold or hot food and drinks that indicates hyperemia or reversible pulpitis. Pain is brief and disappears shortly after removal of the stimulus, it is dull in character. Treatment prognosis can be determined by: I.History of pain: • Spontaneous pain (poor prognosis): Throbbing constant pain that may keep the patient awake at night. This pain indicates advanced pulp damage. • This pain is not related or provoked by a stimulus, and it is usually sharp shooting. Treatment prognosis can be determined by: II.Clinical examination: Abnormal tooth mobility indicates severely diseased pulp or involvement of periodontal ligaments or both. Sensitivity to percussion indicates apical and/or periodontal inflammation. Presence of swelling, sinus, draining fistula or chronic abscess indicates a non-vital pulp. Treatment prognosis can be determined by: III.Radiographic interpretation: Radiographs can determine: • Periapical changes and widening of periodontal ligament space • Rarefaction in supporting bone. • Calcified masses within pulp chamber and root canals • Periapical and interradicular radiolucencies of bone. • Root resorption. Treatment prognosis can be determined by: IV. vitality tests: • In permanent teeth, electric pulp tests and thermal tests may be helpful. • Electric pulp test is unreliable in children as the child may become apprehensive and give a false positive response. • Thermal pulp tests can be done by application of heat (ex:hot instrument ) or cold ( ex: ethyl chloride). In a normal tooth pain will disappear after stimulus removal. If pain persists this indicates pulp hyperemia or pulpitis. If tooth does not respond then pulp is non-vital. • Treatment prognosis can be determined by: V. Signs detected while treating the patient: The signs of acute inflammation within the pulp are not obvious to the clinician apart from the development of pain. The exposure of the pulp chamber gives the clinician a better insight into the pulpal response to the carious process and whether the radicular pulp is inflamed. a.Size of exposure: Small pin point exposure surrounded with healthy dentin (favorable condition for vital pulp therapy) Large exposure with exudate or pus (unfavorable condition for vital pulp therapy) • Treatment prognosis can be determined by: V. Signs detected while treating the patient: b.Amount of bleeding: During pulp therapy Small controllable amount of bleeding (favorable condition for pulp therapy) Excessive uncontrollable bleeding (unfavorable condition for pulp therapy) If, on accessing the pulp chamber, no pulpal tissue or bleeding is encountered, a pulpotomy is not the appropriate pulpal treatment. A non-vital pulpectomy or an extraction is indicated. To sum it up: Factors to consider 1. Age of patient: life expectancy of the tooth to be treated should be considered. 2. History of pain: Patient complaining from provoked pain good prognosis for vital pulp therapy. 3. Clinical examination: • No pathological mobility. • No Abscess, sinus or fistula. • No pain on percussion. • No exudates or pus from large exposure. • Extent of Lesion (MR) • Pulp exposure 4.Radiographic examination: • Favourable Pulp therapy in primary teeth Vital pulp therapy Non-vital pulp therapy Pulp Therapy in Primary Teeth: ✓ Indirect pulp capping. ✓ Direct pulp capping. ✓ Pulpotomy. ✓ Partial pulpectomy. ✓ Pulpectomy. The level of therapy depends upon the level of injury or disease. Therefore, careful diagnosis is mandatory. 1. Indirect pulp capping: • In the majority of circumstances, carious lesions can and should be fully excavated before tooth restoration. A clinical dilemma is presented by a deep lesion in a vital symptom-free tooth where complete removal of softened dentine on the pulpal floor is likely to result in frank exposure. • The advancing front of a carious lesion contains very few cariogenic bacteria. Provided that the bulk of infected overlying dentine is removed, a small amount of softened dentine may often be left in the deepest part of the preparation without endangering the pulp. This is the basis of indirect pulp capping. 1. Indirect pulp capping: It is the procedure where only gross caries is removed from the carious cavity. The carious dentine which if removed will cause pulp exposure is left and covered with a material that promote healing and reparative dentine formation ( Calcium hydroxide or MTA) followed by glass ionomer and composite resin that provides coronal seal. Indication: Teeth with deep carious lesion without any clinical signs and symptoms and radiographic changes. 1. Indirect pulp capping: • All caries is first cleared from the cavity margins with a steel round bur running at slow speed. • Gentle excavation then follows on the pulpal floor, removing as much of the softened dentine as possible without exposing the pulp. • Precisely how much dentine should be removed becomes a matter of experience and clinical judgement, although some have advocated the use of indicator dyes (e.g. 0.5% basic fuchsin) to show when all infected dentine has been eliminated. • In its classical application, the indirect pulp cap was covered with zinc oxide–eugenol cement or glass ionomer and, after observation for several weeks (8weeks), the cavity is re-entered to remove all remaining softened dentine. 1. Indirect pulp capping: • A more modern adaptation of this technique commonly used is to permanently restore the tooth at the same visit. The material that is placed over remaining caries has also been debated, with advocates for resin bonding systems, glass ionomer, and non-setting calcium hydroxide. • As has been demonstrated in a number of studies, the coronal seal is the most important reason for success and therefore a stainless steel crown is the optimal option. Periodic clinical and radiographic reviews are then undertaken to monitor the pulp response. 2. Direct pulp capping: It’s the procedure of covering the exposed vital pulp with a material that promotes healing. Indications: • Small pinpoint exposure surrounded by sound dentin • Normal vital pulp with minimal controlled bleeding at exposure site • Absence of pain with the exception of pain during eating. • Normal vital pulp. • Normal radiographic findings. Direct pulp capping is not recommended in primary teeth, the pulp is usually inflamed prior to clinical exposure. Consequently direct pulp capping following pulpal exposure has a poor success rate as applying a medicament is less likely to stimulate a reparative response in an area of inflamed pulpal tissue. 3. Vital Pulpotomy: It is the removal of coronal pulp tissue till the level of the orifices, then capping the radicular pulp tissues with a suitable material before placing a coronal restoration. Indications: • In teeth with wide pulp exposure when the tissues around it shows slight signs of inflammation • Slight amount of bleeding that is considered normal. • Normal vital pulp • Normal clinical and radiographic signs Vital Pulpotomy Technique: • Administer local analgesia and apply rubber. • Remove coronal pulp with a large round bur or large excavators. Excavators are safer to avoid perforation in the furcation region. • Apply sterile cotton wool soaked in saline for 1–5 minutes to assess heamostasis. • Remove the cotton pledget and check that there is no excessive haemorrhage from the remaining pupal tissue. • Apply medicament to the radicular pulp. • Fill chamber with zinc oxide eugenol cement, pressing on the zinc oxide with a damp pledget to make sure that it is well condensed in the pulp chamber. • Place coronal restoration, preferably a stainless-steel crown. Pulpotomy techniques are based on four main actions: 1) Devitalization: Based on complete fixation of pulp tissues avoiding infection and internal resorption. The most commonly used material is Formcresol which is a strong fixative and antimicrobial agent. 1) Devitalization: The Formcresol used is Buckly’s formcresol which is composed of: 19% formalin 35% cresol Glycerin Distilled water The formaldehyde binds with the pulp proteins leading to tissue fixation. The reaction of formocresol is progressive fixation of pulp tissue with ultimate fibrosis of the entire pulp. Formocresol and a number of other medicaments are no longer used because of worries over their carcinogenic potential. However, formocresol is the material used in Egypt up till now. 2) Preservation: The procedure is based on preserving vitality of the pulp tissues without any inductive process. The most commonly used material is ferric sulphate. It is used as a 15.5% solution for pulpotomy and has a hemostatic and coagulative properties. Ferric sulphate is applied over the pulp stumps for 15 sec. and procedure is repeated till bleeding completely stops. If bleeding does not stop partial pulpectomy or extraction is recommended. Ferric sulphate is the current gold standard for application onto the radicular pulp. • There are some concerns that ferric sulphate is too effective at stopping bleeding and may hide an inflamed radicular pulp. An alternative approach is to apply sterile cotton wool soaked in saline to the radicular pulp stumps for 1–5 minutes to achieve haemostasis. Once haemostasis has been achieved, ferric sulphate is applied. • This approach permits assessment of the radicular pulp to determine, based on haemostasis, whether it is healthy or inflamed. 3) Regeneration: Based on the induction of reparative dentin leaving the underlying pulp vital and healthy. Most commonly used materials are: a)Calcium hydroxide which is highly alkaline( PH 12) consisting of calcium and hydroxyl ions. • The calcium ions stimulate cellular proliferation in pulp tissue ( as the pulp tissue underneath the calcium hydroxide organizes an odontoblastic layer that starts to lay down the reparative dentin) • The hydroxyl ions keep the alkalinity important for proper cellular proliferation. • The use of calcium hydroxide in primary teeth may predispose to internal resorption attracting some osteoclasts that are already present in the area due to the shedding process. 3) Regeneration: b)Mineral trioxide aggregate(MTA): It has an excellent sealing ability, highly biocompatible with high alkalinity (PH12.5) It has the ability to stimulate the formation of dentin bridge adjacent to dental pulp and has antimicrobial properties. A recent Cochrane review (Smail-Faugeron et al. 2014) has identified similar outcomes for MTA and ferric sulphate pulpotomies. MTA is expensive and its routine use for pulp therapy cannot always be justified from a cost-effectiveness viewpoint. c)Growth factors, Enamel Matrix Derivative (EMD) and Bone Morphogenic Protein (BMP) 4) Non pharmacological action: a) Electrosurgery: IT is based on a non chemical devitalization by pulp tissue cauterization. Electrode used for electrosugery b)Laser pulpotomy: It causes a superficial layer of coagulated pulp tissue preserving the rest of the pulp. Laser used for pulpotomy Material used to fill up the pulp chamber and coronal seal : • The classical material used to fill the coronal pulp space is zinc oxide– eugenol. • Following the sealing of the coronal pulp chamber, the tooth should be restored with a stainless steel crown. • Studies have identified the importance of completing all the treatment in one visit rather than temporizing the pulpotomy and restoring the tooth with a stainless steel crown at a later time. 4. Partial pulpectomy: Removal of coronal pulp and as much as possible of the root canal pulp. It’s hard to perform complete pulpectomy in primary molars because of the complexity of root canals, lateral branching and apical ramifications making it impossible to remove all the radicular pulp. Indications: • Primary molars • Vital coronal and radicular pulp that shows hyperemia • No evidence of necrosis or periapical pathosis • Normal radiographic findings. 4. Partial pulpectomy: Technique: • Access pulp chamber as in pulpotomy procedure. • Identify root canals. • Prepare the canals to no more than file size 30. • Dry root canals with paper points. • Select a spiral root canal filler that is two-sizes smaller than the last file used in the root canal (to avoid it being caught in the root canal), thereby minimizing the risk of it fracturing in the root canal. • Mix zinc oxide-eugenol as a slurry and with the help of spiral paste fillers spin this into the root canals. Alternatively, the paste can be carried into the root canals with gutta percha points. • Fill the pulp chamber with cement. • Restore the crown, usually with a stainless steel crown 4. Partial pulpectomy: • The disadvantage of the technique is that extra time is needed and therefore excellent behaviour management techniques are required. • Consequently, this technique may be reserved for strategic teeth such as retaining the second primary molars or where there is a missing second premolar and the decision has been made with orthodontic colleagues to retain the second primary molar. Pulp Therapy in Primary Teeth: (Recap) ✓ Indirect pulp capping. ✓ Direct pulp capping. ✓ Pulpotomy. ✓ Partial pulpectomy. ✓ Pulpectomy. The level of therapy depends upon the level of injury or disease. Therefore, careful diagnosis is mandatory. Biological approach: Placing a stainless steel crown with the Hall technique: a biological approach with no caries removal both the Hall technique with no caries removal and indirect pulp capping with partial caries removal rely on an excellent coronal seal. Where this is achieved in the appropriate tooth, the inflammation present is reversible and the pulp is able to repair itself. These techniques both rely on an accurate assessment of pulpal health. Indirect Pulp Capping and the Hall technique rely on an accurate diagnosis of pulpal health. (See the Hall technique electronic users manual (Innes et al. 2010).) Follow-up: Teeth that have undergone pulp therapy should be reviewed clinically and radiographically. Clinically, the following criteria indicate success: • Absence of symptoms • Absence of any abscess or draining sinus • no excessive mobility or tenderness • Retention of the tooth until it would exfoliate naturally. Radiographically, the following should be observed: 1. No evidence of bone loss in the furcation region. 2. No evidence of internal resorption. Internal resorption indicates chronic inflammation and the activity of giant cells causing resorption of the dentine. It creates few symptoms and is usually detected as an incidental finding on radiographic examination. It should be considered as a form of irreversible pulpitis. Aim: To describe the techniques to manage vital, pulpally involved primary teeth. Objectives: Subject Title Goes Here • Describe the pulpal morphology of primary teeth • Explain the signs and symptoms of irreversible pulpitis in children • Evaluate different methods for managing the vital pulp of the primary molar and apply them where appropriate References: • • • “treatment of deep caries, vital pulp exposure, and pulpless teeth.” Dentistry for the Child and Adolescent, by Ralph E. McDonald et al., Mosby, 2010, pp. 343-363. American academy of pediatric dentistry (2014). Guideline on Pulp Therapy for Primary and Immature Permanent Teeth , 244-248. “Operative treatment of dental caries in the primary dentition”.Pediatric dentistry, by Richard Wellbury et al.,Oxford, fifth edition,2018,pp.149-151 • Duggal, M.S., Curzon, M.E.J., Fayle, S.A., et al. (2002). Restorative techniques in paediatric dentistry (2nd edn). Taylor & Francis, London. (A superb colour atlas and pictorial guide.) • Smail-Faugeron, V., Courson, F., Durieux, P., et al. (2014). Pulp treatment for extensive decay in primary teeth. Cochrane Database of Systematic Reviews, 8, CD003220. Reading material: Students are advised to review any relevant teaching provided in the first year. In addition they are advised to read relevant sections of the following texts: • Prevention and Management of Dental Caries in Children, Scottish Dental Clinical Effectiveness Programme http://www.sdcep.org.uk/published-guidance/caries-in-children/ • Welbury R et al; Paediatric Dentistry; 5th Edition, Oxford Press • Koch G et al; Pediatric Dentistry - a Clinical Approach; 3rd Edition, Wiley Blackwell