9 Pulp Therapy by Go16d1EG


									                              By the name of Allah

 **** The doctor skipped a lot of slides and a lot of info plz go and read it alone.

                                       PART 1

We will continue our last lecture today we will talk about pulpotomy

The definition of the pulpotomy is amputation of the coronal pulp tissue so only
the pulp tissue in the pulp chamber and leaving the radicular pulp.

Treatment of remaining vital radicular pulp tissue surface should reserve the
vitality and function of all or part of remaining radicular portion, So in other word
the radicular should be vital and the coronal pulp chamber filled with suitable
base and tooth restoration.


   1- Primary teeth when infected coronal tissue can be imputed and the
      remaining tissue should be vital or affected bs still vital that is means
      reversible pulpitis and this can evaluated by clinical x-ray or RG.
   2- Carious pulp exposure in this case if u remove the dentine of the caries the
      pulp tissue will be exposed so u perform to do pulpotomy (as we said if we
      have a deep caries and we remove it we will need a pulp therapy and then
      SSC as a final restoration).
      When we look at the x-ray we want to have a tooth wish is health and vital
      and the radicular pulp is at least is vital and the periapical area should also
      be healthy and look normal so what we mean that we don’t want any
      periapical and bone resorbtion o any furcation radiolucent or any widening
      PDL or any abscess or mobility or anything which indicated irreversible

   3- Traumatic pulp exposure.

   4- Primary molars with loss of more than 2/3 of marginal ridge ex: class 2
      more than 2/3 is lost is indicated that the pulp is involved.

In pic slide 32 :

If More than 2/3 is involve we need pulpotomy

In pic slide 34,35 :

75 need ?? no 74 ?? yes


1-Inability to establish haemostasis:

We usually remove the coronal pulp and then we make a clinical judgment (we
look at the canal and we apply a cotton roll pressure with normal saline on the
radicular pulp tissue just for few seconds and then we will remove it , if there is
excessive bleeding that fill the root chamber then that’s mean that even the
radicular pulp is also inflamed ((irreversible pulpitis)) , no bleeding at all is also a
problem cuz that mean ((necrosis)) , what we want to see a minimal bleeding
which is stop when we apply a pressure indicate to ((a healthy pulp)).

** if we have a lot of bleeding which fill the crown we have to do pulpectomy
(RCT) or extraction .

2-Any Acute odontogenic infection (abscess, pus, fever, facial swelling, cellulitis)
all these indicate that these tooth is not indicated for pulpotomy.

3-The Tooth is unrestorable ((can’t do restoration for the tooth)) a badly broken
tooth, the pulp is healthy but the margin or the rest of the tooth is not restorable,
so what is the use of doing pulpotomy if we won’t be able to use a restoration

4-The tooth is soon to exfoliate (mobile, there is less than 1/3 of the root length)
so these tooth is going to be lost, so we don’t do pulpotomy for it.

5-Excessive tooth mobility (any internal or external root resorbtion is
contraindicate for pulpotomy).

6-Medical history (any pt’s with cardiac problem which indicate that these pt’s
may have sub acute bacterial endocarditic we don’t do any form of pulp therapy,
we usually prefer to do extraction for these pt’s, also any immunocompromised
pt’s due to primary reason such as a basic problem in the immune system or
secondary reason such as HIV or leukemic or radiotherapic pt’s and these is the
more often).

In Pic slide 37, 38 :

These are a badly decayed 54, 64 even if we do a pulpotomy here we can’t do any
kind of restoration so we prefer to extract it …. Here we have internal root
resorption and furcation radiolucent (furcation radiolucent which also
contraindicate for pulpotomy).

In Pic slide 39 :

This is a case where we have a periapical abscess and furcation radiolucent ….

In pic slide 40 , 41 :

Here sinus tract which is also contraindicate to pulpotomy and we have abscess
it’s contraindicate to pulpotomy,,,, the treatment plane is extraction for 74
because badly destructed, furcation radiolucent, root resorption ……. We have 75
the root is intact, furcation radiolucent so contraindicated to pulpotomy.

In pic slide 42:

Another example here 84 we have caries if we can remove it without expose the
pulp we build up or fill the cavity with GI then we place a crown if it’s very close to
the pulp we may call it indirect capping ….. here 85 periapical is fine but we have
mesial carise and its extend near to the pulp so we do pulpotomy …… here 74 it’s
like 84 …. Here 75 like 85.
In pic slide 43 :

we have 84 we do restoration ,,,,, 85 we do pulpotomy.

Objectives :

   1- The vitality of radicular pulp maintained.
   2- No prolong adverse clinical signs or symptoms such as prolong sensitivity
      pain or swelling (y3ne ma bdi el patient yrja3 yshke).
   3- No evidence of internal or external resorbtion (by X-ray).
   4- No breakdown of tissue, no harm to succedaneous tooth

All of this should be take care of.

***The doctor skipped a slide read it by your self


Basically with the bur going to remove the caries and take a part of the pulp and
put a suitable liner and finally a restoration , so should do it with rubber dam and
local anesthesia and the access as u did in ENDO .

So remove all the caries before intering the pulp always ( lam enshel el caries
abeel ma nfot bel acses ) WHY ? To prevent anything from entering the pulp , so
we use a high speed burs for caries and access usually we use a peal shape bur .

Then amputation of the pulp to level of cervix ( el 5aser )

Then medicament used to fix the pulp and arrest bleeding like (formocresol ,
feeric sulfate )

Then IRM dressing like we put GI and the crown above it (SSC or strip crown on
the ant teeth)

***The doctor start to talk about pic but there is no pic so just understand what
to do.

Here the teeth we removed all the caries u should never leave any caries then you
start to amputate your pulp look in the pic there is aminimal bleeding it is
acceptable so you squeeze for 1 or 2min and remove the cotton if there is still
hemorrhage so it is contains and u should not continue your pulp therapy then
we applied our medicament formocresol , feeric sulfate after that the bleeding
gone then we fill it with IRM, GI and the crown .

***The morphologic and the shape of the root u should look at by your self

In the pic slide 49:

this is after the condensation of IRM in 55 u should push it with a cotton palate
mnblelha with water and push your arm as fare as u can and be sure that it is well
condensed and it closed the root or the orifices of the root if it is not well
condesnd it is not accebtable

Medicemnet :

       All the medicament should follow these criteria :

              1-   non-toxic.
              2-   antimicrobial.
              3-   anti-inflammatory.
              4-   haemostatic.
              5-   promote true healing of pulp tissue.
              6-   not to interfere with normal physiologic tooth process.

there is several types which chemical and nonchemical

chmical agents :

    formocresol
    calcium hydroxide

      ledermix
      ferric sulfate
      gluteraaldehyde
      MTA

Non chemical :

    Electrosurgery
    laser for amputation
    Bone morphogenetic proteins

                       Now we start with the chemical technique :

Formocresol (FC):

Rationale for use of formocresol …… FC it’s a golden standard for pulpetomy

..rational for FC not clear they used in the beginning ,,,it’s fixes affected and
infected radicular tissue so that a chronic inflammation replaces an acute
inflammation ,,, a FC pulpetomy the pulp remains in a stable condition until pulp
exofilate this is after you applied the FC it’s just keep the pulp fix where nothing
is happening until it’s foliate ,,, why we say it’s nothing happened cause the ideal
we put the medcreament to promote the healing to be there secondary dentine
formation and regeneration to the pulp tissue which is something they dreaming
about cause we are until now we don’t have medcrement do that …

The affects when we apply the FC either local effect or systemic affect

Local affect : which affect the pulp and the periapical area

Systemic affect :which is affect on the whole body

,,,,,,, the affect on the pulp include fixation ,,,she start explain on pic dr Saied you
see zone here where the fixation, under it coagulation, necrosis, and the last one
is vital tissue ,,, and may be here can be necrotic inflammation.

 ,,,,,, the affect on periapical there are some studies they said that it is toxic and
there is odontogenisty allergic reaction

Ringelstein and seow they had a major studies ,,they said there is a high revelance
of foramena located in the furcation of primary molars with no difference
between the E’s and the D’s and these accessory canals can provide pulpal
periodontal communication with important clinical implication in endo and perio
treatment ,, sometimes after you amputated your pulp, these accessory canal
may be we will find microorganism which will enter through them and cuz a
problem to the radicular area and a lot of accessory canal are present in the
furcation area of the primary teeth , FC can go to the furcation area through
these accessory canal.

SOOO.. FC can go to the furcation area through 1)pulp tissue 2)accessory canal .

The association of dentigorus cyst 30% of pulp treated teeth presented with DC
especially in mand. Molar.

The association of FC with developmental defect of enamel (enamel hypoplasia)
especially in the premolar, also they found that FC in the primary premolar
enhance the exfoliation of it and accelerate the eruption of the permanent one.

They make a study of toxicity on the enamel esp. on the dogs and they end with
organ failure and death, after this study they start to dilute the FC concentration
by 1-5% and they found that it does the same job!!

The formulation that we use it now is buckley’s FC :

It’s a preparation that is done through addition of a formaldehyde ( the source of
FC) , tricresol , glycerol, and water. After this it’s diluted in a ratio 1-5 to be less

Ferric sulfate :

is another material that has less local and systemic toxicity than FC but until now
there is nothing aginst FC and there is no direct relation with cancer or toxicity
but we use ferric sulfate just cuz it’s safer!!

In jordan we still use both of them but the most common one is ferric sulfate.

It’s astringent comes as 15.5% feSO4 ( ferric sulfate) in aqueous vehicle and
originally used as a haemostatic agent on retr cord in crown and bridge , it causes
aggultin of the blood vessels due to rx. of blood with both Fe and SO4 ions, and
the agglutinated form plugs occlude the capillary orifices fa beba6l el bleeding.

It’s considered very good for decrease the chance of the inflammation.

Like the FC we have to use cotton roll with pressure for few seconds on the pulp
tissue to remove any excess material.

The benefit of ferric sulfate :

1-non toxic \ non cariogenic.

2-readily available.

3-short application time ( 10-15s). (((FC 5 min. )))

4-succss rate are comparable with greater than those of FC.

*** FC is the toxic material but ferric sulfate is not toxic !!!

MTA (mineral trioxide aggregate) :

Can also applied on pulp tissue after we irrigate with saline.

                         Now the non – chemical technique :

Lasers and electrosurgery :

It is a technique used to remove the pulp 3n 6are2 el laser or 3n 6are2 el electro
surgery .

Or endogane it is new material it is as a gel applied 3la el pulp tissue o also b3mal
arrest lal bleeding and it provide signal lal pulp tissue for undeferential cell to
produce more pulp tissue and odontoblast to perform dentine but still not widely
used coz it is expensive.

Success rate factor :

    The teeth location in the dental arch usually the E success more than D.
    Type of immediate restoration the mean if u put the crown in straightway
     u will get a better success SOOO if u restored the teeth with the crown
     immediately it is more success than if u dismiss the patient with the IRM
     only and he came back for the crown .

** the dr. Said that we have to take X-ray and follow up the pt cuz it may appear
success clinically and failure in the x-ray cuz of chronic periapical lesion !!!

                                  END OF PART 1

  We did our best and we wrote every single world,, forgive us for any mistake

                              Done by: ENAS & SARA

           And spical thanx for FATOOOOM for the help (( 3eshiiiiii :P ))

                                    Part 2 (last year)


-Removal of the whole pulp system then u restore the canals with medication.

-Here in primary teeth we don’t use gutta-percha because it’s a hard material that
won’t resorb by the permanent teeth so we need to use a material that will

-In the preparation we don’t do step back technique we only use 2 files the largest one
is about 35 so we start with 20 then 25 then 30,,Just a quick filing.

   - Canals debrided and disinfected with normal saline irrigation or NACL.
   - Dry the canals with paper points.

    - determination of working length :
CWL=EWL – 2 mm from the apex, because we don’t want to go beyond the apex and
hit our permanent teeth.
    - Instrumentation:
we don’t use US(ultra sonic),Gates-glidden , Pesso drills ,we Ni-Ti files because its
flexible and it’s the best.
    - irrigation
     Sodium hypochlorite (NaOCl)
     Normal Saline NS

Then Dry with paper point.

    root canal filling materials

    - KRI- paste
The main ingredient is IODOFORM that’s why it has a very high success rate because
its antibacterial.
     disadv: it causes yellow- brown staining so we don’t use it for ant teeth its only
        for molars.

   - ZOE

It’s not IRM it’s a pure ZOE its only zinc and Euogenol it has a long setting time it
doesn’t set straightaway ant its runny like CH while IRM has resin that makes it hard.

  - vitapex
which is CH + Iodoform .

   - ENDOFLAS is its commercial name.
So u have to know that there is :

- CH alone.
- CH +I
- KRI paste

The Doc said that u don’t need to memorize the percentages but only to know
that KRI paste has the higher SR.

Slide :
1st of all , young permanent teeth means that the root is incomplete like a
permanent molar in A T yrs old child where the ape% is not complete yet so we are
talking about teeth in adolescence where teeth are partially erupted or Just erupted and
the roots are not completely formed.

    Apexogenesis

it’s a vital pulp therapy procedure that will lead to continuous formation of the
there are 2 types in permanent teeth :
1-partial pulpotomy
2-cervical pulpotomy

   - partial pulpotomy: removal of a part of the pulp tissue (Just the upper 2mm ) in
       this case we call it cvek pulpotomy.
**cvek –technique:
-remove the upper 2mm of the pulp ,then we place our medica5on (CH or MTA) then
we place a base (GIC) then restore it using composite for ant teeth or amalgam for
post teeth , then after that we follow up after few months or year ,, the apex must be
completely formed that means that our treatment was successful.

~ factors affecting success ~ :

   - aseptic technique : and after we remove the 2mm of the pulp u have to irrigate
     with Normal saline to have a clean area then put a cotton pellet on the top and
     make sure that the hemorrhage stop but if there is a continuous bleeding that
     mean that we have irreversible pulpitis (so in this case we don’t do pulpotomy
     because we must remove more pulpal tissue up to the cervical part).

   - marginal seal of the permanent restoration (the most ideal one is SSC for

  - cervical pulpotomy:
Remove everything up to the cervix like what we do in primary molars but the
materials we use are different.

Place CH or MTA then build with GIC then restore it with composite for ant teeth and
SSC for molars.

    Apexification

Like RCT but in young permanent teeth, where the apex is not completely
formed and the tooth is not vital and we need the apex to form , here we can’t do RCT
because the material will go beyond the apex so we need to perform a procedure to
allow the apex to close although the pulp is not vital .
while in Apexogenesis the pulp is vital so it’s a procedure that we make to
maintain the vitality of the pulp so the apex will continue its formation but in
apexification the pulp is not vital so we relay on Hertwing of epithelia root sheeth
cells which are vital cells and we Just need to stimulate these cells to go on because
they are the cells which cause the root to continue growing and this is done by
removing any inflammation(necrotic pulp tissue) by filing ,irrigation, cleaning and
shaping then placing medication to stimulate these cells like CH which is antibacterial
and will stimulate these cells to continue apex formation.

Pic: Avulsed tooth
It’s a tooth that was traumatized and removed from the socket then we splinted it and
did apexification
    - Here we have 2 technique:

The 1st technique: CH

Initially we place CH then let the root to form, so then we can place GP because we
have a hard tissue to condense against it ,and this CH must reach the apex because
where we place CH we will get the closure so if we place CH short the apex will close
at the middle of the root. In this technique we have to wait from 6-18 months
depending on pts age and if there is an inflammation.
The 2nd technique: MTA
we put MTA at the end of the root as a plug and on the same day you can place your
GP (in one visit) so in this case you don’t have to wait for the apex to continue
formation or the child to grow up (quicker technique).

                                      The end


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