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Pediatric  Dental  Health

July 28, 2005

Introduction to Pediatric Pulp Therapy

Many children have painful inflammation or infection of the dental nerve and pulp. This problem is usually caused by deep dental caries. There are a variety of clinical treatments available to remedy such problems, ranging from a minimally invasive procedure such as the indirect pulp cap - to a more invasive procedure such as the pulpectomy.

This article will focus on the following topics in pediatric pulp treatment:
•Rationale for Pulp Treatment
•Treatment Considerations
•Assessment and Diagnosis of Pulp Status
•Management of Deep Carious Lesions
•Indirect Pulp Cap
•Direct Pulp Cap

Rationale for Pediatric Pulp Therapy
•To retain the tooth so it may fulfill its role in the dentition.
•To capitalize on the healing potential of the noninflamed remaining portions of the pulp.
•Premature loss of primary teeth may result in the following sequelae:
•Loss of arch length, insufficient space for erupting permanent teeth, ectopic eruption and impaction of premolars, mesial tipping of molar teeth adjacent to extraction areas, extrusion of opposing permanent teeth, shift of the midline, and development of abnormal tongue postures.

Treatment Considerations in Pediatric Pulp Therapy
•Contraindicated for patients:
•with conditions that make them susceptible to subacute bacterial endocarditis, nephritis, leukemia, solid tumors, and cyclic neutropenia,
•with unmanageable behavior.

Clinical Assessment and Diagnosis of Pulp Status
• Visual and tactile examination of carious dentin.
• History of spontaneous unprovoked pain.
• Constant pain.
• Pain from percussion.
• Pain during the night.
• Degree of mobility.
• Palpation of surrounding soft tissues.
• Radiographic.
• Thermal and electric testing unreliable in primary teeth and permanent teeth with open apices.

Radiographic Assessment and Diagnosis of Pulp Status
• Radiographic examination of: periradicular and furcation areas, pulp canals, periodontal space, developing succedaneous teeth.
• Bitewing radiograph: best for detecting a furcal radiolucency in a primary molar.
• Occlusal radiograph: best for detecting periapical radiolucency in maxillary or mandibular anterior.
• Primary molars have furcal (not periapical) involvement.

Management of Deep Caries in Primary and Young Permanent Teeth
• Three vital techniques:
• indirect pulp capping,
• direct pulp capping, and
• coronal pulpotomy.

Treatment Objective for Vital Pulp Therapy
• preserve the vital pulp,
• preserve the space for the underlying permanent tooth,
• eradicate potential for infection.

Definition and Rationale for the Indirect Pulp Cap
• Definition: the application of a medicament over a thin layer of remaining carious dentin, with no exposure of the pulp.
• Can be done in primary and permanent teeth.
• Treatment Objective: to generate reparative dentin formation.
• Rationale: There are three dentinal layers in a carious lesion:
• (1) a necrotic, soft, brown dentin outer layer, teeming with bacteria;
• (2) a firmer, discolored dentin layer with fewer bacteria; and
• (3) a hard, discolored dentin deep layer with a minimal amount of bacterial invasion.

Indications for the Indirect Pulp Cap
• Absence of spontaneous pain.

Contraindications for the Indirect Pulp Cap
• Prolonged spontaneous pain, particularly at night.
• Excessive tooth mobility.
• Parulis in the gingiva approximating the roots of the tooth.
• Widened periodontal ligament space, interradicular or periapical radiolucency.

The Indirect Pulp Cap in One Appointment
• 1. Local anesthesia. Rubber dam.
• 2. Cavity outline with a high-speed handpiece.
• 3. Remove soft, necrotic, infected dentin with a large round bur in a slow-speed handpiece without exposing the pulp.
• 4. Irrigate the cavity and dry with cotton pellets.
• 5. Cover the remaining affected dentin with a hard-setting calcium hydroxide dressing.
• 6. Fill or base the remainder of the cavity with a glass-ionomer cement to achieve a good seal.
• 7. Use composite resin, or a stainless steel crown as a final restoration.

Definition and Treatment Objective for the Direct Pulp Cap
• Definition: the placement of a biocompatible agent (calcium hydroxide) on healthy pulp tissue that has been inadvertently exposed from caries excavation or traumatic injury.
• Treatment Objective: to seal the pulp against bacterial leakage, encourage the pulp to wall off the exposure site by initiating a dentin bridge, and maintain the vitality of the underlying pulp tissue regions.

Indications for the Direct Pulp Cap
• (1) “pinpoint” mechanical exposures that are surrounded by sound dentin,
• (2) asymptomatic tooth.

Contraindications for the Direct Pulp Cap
• (1) carious exposure,
• (2) spontaneous and nocturnal toothaches,
• (3) excessive tooth mobility,
• (4) thickening of the periodontal ligament,
• (5) radiographic evidence of furcal or periradicular degeneration,
• (6) uncontrollable hemorrhage at the time of exposure, and
• (7) purulent or serous exudate from the exposure.

Direct Pulp Cap Requirements
• The capping material must prevent bacterial microleakage.
• The capping material must directly contact pulp tissue to exert a reparative dentin bridge response.
• Investigations support the use of hard-set calcium hydroxide cements.
• Success rate 80% for well-chosen cases.
• An alternative material: Mineral trioxide aggregate (MTA). The material consists of tricalcium silicate, tricalcium aluminate, tricalcium oxide, and silicate oxide.

Direct Pulp Cap Technique
• Dry the exposure site with a sterile cotton pellet.
• Apply hard-set calcium hydroxide cement (or MTA).
• Seal with amalgam or composite restoration.

An article in the Journal of the Canadian Dental Association discusses Vital pulp capping. The article describes two techniques that have demonstrated success with vital pulp capping — the calcium hydroxide technique and the total etch technique.

Stockton LW: Vital pulp capping: a worthwhile procedure. J Can Dent Assoc 1999; 65:328-31.

Copyright ©2005 Daniel Ravel DDS, FAAPD

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