Pulp Therapy

Question 1

Treatment objectives

Answer 1

• Treatment objectives
❖Eradicate potential for infection
❖Maintain tooth in quiescent state
❖Preserve space for underlying permanent tooth
❖Primary molar vital pulp therapy outcomes are superior
when restored with stainless steel cr

Question 2

Indication for protective base

Answer 2

Tooth with deep exposed dentine after caries removal

Question 3

Objectives of protective base

Answer 3

Preservation of vitality, minimize injury to pulp
Minimize postoperative sensitivity
Vital Primary Tooth
Stimulate secondary dentine formation

Question 4

Indications for IPT

Answer 4

❖Asyptomatic tooth with deep carious lesion
❖Vital pulp

Question 5

Obj of IPT

Answer 5

Preservation of vitality
❖Arrest of caries advance
❖Formation of tertiary dentine

Question 6

• Materials for indirect pulp capping:

Answer 6

• Materials for indirect pulp capping:
  ❖Traditional materials: calcium hydroxide, ZnO eugenol,
  ❖New materials: Dentin bonding agent, resin modified GIC

Question 7

Technique involved in indirect pulp treatment

Answer 7

• Technique
• Local anaesthesia
• Isolate with rubber dam
• Establish cavity outline
• Remove superficial debris and majority of soft necrotic
dentin with slow hand piece and round bur
• Stop excavation as soon as the firm resistance of sound
dentin is felt
• Flush cavity with saline and dry with cotton pellet
• Cover residual caries with calcium hydroxide
• Fill the rest of the cavity with reinforced ZOE
• Final restoration with SSC
• Re-entry for completion of caries removal is not necessa

Question 8

Direct Pulp Capping (DPC) Indications and C.I

Answer 8

Direct Pulp
Capping (DPC)
• Indications
❖Small mechanical exposures in primary teeth
❖Small traumatic exposures in primary teeth
- Contraindications
❖Carious exposure in primary tooth
❖Persistent inflammation
❖Internal resorption
❖Calcific metamorphosis

Question 9

Obj and materials for DPC

Answer 9

Objectives
▪ Preserve pulp vitality under tertiary dentine bridge
• Ca(OH)2 may produce internal resorption
• Pulpotomy is preferred due to predictable outcomes

• Materials for DPC
• Calcium hydroxide
• Zinc oxide Eugenol
• Mineral trioxide Aggregate

Question 10

About Direct pulp capping
What could cause internal resorption?
What are some of the reasons why its C.I in primary teeth?
What is important for good prognosis?
If there’s exposure on the axial wall of the pulp, what is the preferred treatment option?

Answer 10

▪ caries process or pulp capping materials may cause chronic inflammation which may destroy
odontoblast layer and recruit clastic cells—internal resorption

▪ High cellular content, fast inflammatory response and poor
localization of infection are some reasons why DPC may be
contraindicated in primary teeth

▪ Location of pulp exposure is important for good prognosis

▪ If exposure is on the axial wall of the pulp, a pulpotomy is
preferred to a pulp cap.

Question 11

Definition of pulpotomy and Indications

Answer 11

Vital pulpotomy
Pulpotomy is a procedure in which the coronal pulp (or part of it) is
amputated and a medicament is placed over the radicular pulp to
help maintain its vitality.

Indications
• Carious exposure of pulp
• Iatrogenic pulp exposure
• Inflammation limited to coronal pulp with vital radicular pulp
• Restorable tooth

Question 12

Contraindications of vital pulpotomy
(Clinical)
Mnemonic-P^2LUMS^2–T

Answer 12

—Spontaneous pain
—Swelling or sinus/fistula
—Tenderness to percussion
—Pathologic tooth mobility
—Uncontrolled bleeding from amputated pulp stump
—Pus or exudate from exposure site
—Large carious lesion with non-restorable crown
—Medical contraindications (e.g., heart disease)

Question 13

Radiographic Findings (Contraindications)
MNEMONIC——P^2IER

Answer 13

Radiographic Findings (Contraindications)
—Periapical or radicular radiolucency
—Internal root resorption
—External root resorption
—Root resorption more than one-third of root length
—Pulp calcification

Question 14

Objective of pulpotomy

Answer 14

Objectives
• To maintain tooth in symptomless state until exfoliation and no harm to succedaneous tooth

Question 16

Vital pulpotomy
• Pharmacologic agents:

Answer 16

Vital pulpotomy
• Pharmacologic agents:
• - Formocresol
• - Calcium hydroxide (not used for primary teeth)
• - Glutaraldehyde
• - Paraformaldehyde (Devitalization pulpotomy): two visits
• - Ferric sulphate
• - Mineral trioxide aggregate (MTA) , Bioactive glass, BMP

Question 17

• Non pharmacologic agents:

Answer 17

• Non pharmacologic agents:
• - Laser
• - Electrosurgery

Question 18

About Vital pulpotomy medicaments
1.What are the other names for devitalization?
2.What are the features?
3.Mention examples

Answer 18

1.Mummification
Cauterization

2. Destroys or
   mummify vital
   tissues
3. Formocresol
   Electrosurgery
   Laser
   Paraformaldehyde devitalizing paste

Question 19

About Vital pulpotomy medicaments
1.What are the other names for preservation?
2.What are the features?
3.Mention examples

Answer 19

1. Minimal devitalization noninductive
2. Maintains vital tissue, with no induction of reparative dentine
3. ZnO Eugenol
   Glutaraldehyde
   Ferric sulphate

Question 20

About Vital pulpotomy medicaments
1.What are the other names for Regeneration?
2.What are the features?
3.Mention examples

Answer 20

1. Inductive
   reparative
2. Formation of Dentin bridge
3. Examples
   Ca(OH)
   Bone morphogenic protein, MTA

Question 21

What medicament is the “gold standard for pulpotomy”

Answer 21

Formocresol

Question 22

Formocresol was introduced by?(year)
Clinically emphasized by?(year)

Answer 22

introduced by Buckley 1904
• Clinically emphasized by Sweet in 1930

Question 23

Constituents of formocresol and percentages

Answer 23

19% formaldehyde, 35% cresol, 15% water and glycerin

Question 24

Concentration of formo
How its done

Answer 24

• Buckley formocresol is 20% 1:5 concentration
• This is done y adding 3 parts of glycerin to 1 part of distilled water,
then 1 part of formocresol to 4 parts of diluent

Question 25

Success rate of formocresol

Answer 25

70-97%

Question 26

Disadvantages of formo

Answer 26

Mutagenic cytotoxic carcinogenic and poses threat to humans

Question 27

Zarzar 2003 proposed strong but not sufficient evidence of?

Answer 27

Strong but not sufficient evidence of leukemia and cancer of the paranasal sinuses Zarzar 2003

Question 28

• IACR 2004 classified formaldehyde as

Answer 28

carcinogenic to humans.

Question 29

MOA of formo

Answer 29

• Mechanism of action: prevents tissue autolysis by bonding to protein. This binding is a reversible process accomplished without changing the basic structure of protein molecules

Question 30

• Histological zones in FC treated radicular pulp

Answer 30

• acidophilic zone: fixation (coronal) • Pale staining zone: atrophy (middle) • Broad zone of inflammatory cells (apical)

Question 31

Features of FC treated radicular pulp

Answer 31

• Bacteriocidal • No dentinal bridge but calcific changes evident • Persistent chronic inflammation

Question 32

Local and systemic complications/diasdvantages of FC Mnemonic- Local-SEC Systemic-HIM

Answer 32

Local: • Succedaneous tooth damage • Exfoliation accelerated • Cellular toxicity Systemic: • Immune sensitization risk • Humoral and cell-mediated responses • Mutagenic and carcinogenic potential

Question 33

Formocresol Pulpotomy-Technique

Answer 33

Formocresol Pulpotomy-Technique • Give LA • Isolate with rubber dam • Use No 330 bur to create your cavity outline • Remove all carious dentine and the roof of the pulp chamber with a slow speed round bur. • Amputate the coronal pulp with a slow speed round bur or a spoon excavator • Irrigate gentle with normal saline • Place a moisten cotton pellet on the orifice of the canals to achieve haemostasis this should be between 3-5 minutes • Place cotton pellet moistened with formocresol (squeeze out excess) on pulp stump for 5 minutes • The pulp stump should appear blackish brown • If there is bleeding check for residual pulp tissue or tooth may be non-vital • Remove the formocresol moistened cotton pellet • Fill the pulp chamber with zinc oxide eugenol • Restore with stainless steel crown • Follow up

Question 34

Ferric sulphate is a what?

Answer 34

Astringent

Question 35

MOA of ferric sulphate

Answer 35

• Mechanism of action- forms a ferric ion protein complex that mechanically occludes cut blood vessels

Question 36

When was Ferric sulphate Proposed as a pulpotomy agent and by who?

Answer 36

1988 (Landau & Johnson).

Question 37

Whats an advantage of ferric sulfate over formocresol

Answer 37

Causes less inflammation than formocresol when used as a pulpotomy agent.

Question 38

Ferric sulfate is not a fixative but it is ——— in nature

Answer 38

Bacteriostatic

Question 39

Ferric sulfate is not toxic. T/F

Answer 39

T

Question 40

What’s the only difference in the procedure when using ferric sulfate over Formocresol

Answer 40

Same procedure as formocresol but should be placed for 10-15 sec (shorter application time) on pulp stump.

Question 41

Glutaraldehyde has larger molecules than formaldehyde, what happens as a result ?

Answer 41

Has larger molecules than formaldehyde, and as a result diffusion through the tissues is reduced.

Question 43

Adv of Glutaraldehyde over formocresol

Answer 43

ADVANTAGES OVER FORMOCRESOL • Superior fixation by cross linkage of 2 aldehyde rings • Diffusibility is limited. Hence; there is less chance of causing pulp necrosis. • 15 – 20 times less toxic than formocresol Jeng 1987 • Does not stimulate a significant immune response • Minimal systemic distribution because of larger molecular size and less chance of penetrating the apical foramen • It is readily metabolized, 90% of the drug is metabolized within 3 days.