 Dentin:
Wide dentinal tubuls;
 Additional channels over the pulp horns;
 Wide dentinal canals above the root delta;

 Pulp:
Maturity level of pulp;
 Size of the pulp chamber ;
 Width of the root canals.

 Degree
of development of root canals:
Formation of root walls;
 Formation of the apex;

 physiological
resorption:
Degree of root degradation;
 Reactivity of the pulp;

 Degree
bone.
of development of the alveolar
4 yrs.
pre eruptive
period
Root construction
5 yrs
Functional period
Root resorption
 There
are several reasons for a dental pulp
to become inflamed, but the far the
commonest is as a sequel to dental caries;
 Dental caries in primary tooth progresses
rapidly to relatively thin enamel and
penetrates dentin;
 The insult from bacterial toxins stimulates
the underlying pulp to respond by mounting
an inflammatory reaction – reversible
pulpitis.
 Infection:


 It


For deep cavities;
Secondary caries;
is caused by:
microorganisms;
Microbial toxins;
 Dentinal
degradation products.
Microorganisms
Exo-and endotoxins
Degradation of odontoblastic processes
They are moving through dentine tubules
They are reaching to odontoblasts and
nerve receptors
Is induced reflective
reaction
Overcoming
protection
Protection
When compensatory
mechanisms are running out
Inflammation
 Exudation;
 Alteration;
 Proliferation.
Serous
inflammation
Serum
diapedesis
Plasma
diapedesis
Pulp abscess
Cell
diapedesis
Increase
granular
cytoplasm
Relocation
of nuclei
in dentine
tubule
Disoriented
odontoblasts
Damage to
the pulpdentin
border
Destruction
of the
odontoblasts
Depolymerization
of the
intercellular
space
Degradation of
collagen fibers
Destruction of
the vascular
walls
Develops
chronic
ulcerative
pulpitis
Chronic pulpitis
development of
fibrosis
Growth of young
granulation tissue
fibrous pulpitis
granulomatous
pulpitis
 Causing
a massive increase in pulpal
response;
 This is characterised by irreversible
inflmmation and tissue necrosis directly
adjacent to the site of exposure;
 Bacteria and their products will progress
through the pulp tissue, resulting in
irreversible inflammation;
 The response of pulpal and periodontal
tissues to such injury can lead to one of
several outcomes:
 The
periradicular tissues may affected
(periradicular periodontitis), with eventualy
involvement of associated tissue;
 If the exposure site involves a large area,
Hyperplastic pulpitis (pulp polyp) may occur;
 The tooth may be subject to pathological
resorption – for example, internal
inflammatory resorption.
History unreliable;
Clinical examination:
Visual
examination
Probe
Percussion
Paraclinical
examinations
Depth of the carious destruction;
The color of carious dentin;
Smell of carious defect;
Redness of alveolar mucosa;
Fistula.
Consistency of
the carious
dentin;
Carious dentin
thickness;
Communication
with the pulp;
Tooth motility.
Radiography;
Electro
odonto
diagnosis
Child
crying;
Waking up
in the
night;
Whether or
not there a
swelling;
Big carious
defect
Emergency
treatment on the
same day
Transient
pain
Long
lasting
pain
Presence
of fistula
Urgency will appear
at any moment.
 Acute
pulp
inflammation:
 Pulpitis acuta serosa
partialis;
 Pulpitis acuta serosa
totalis;
 Pulpitis acuta
purulenta partialis;
 Pulpitis purulenta
totalis;
 Chronic
pulp
inflammation:
 Pulpitis chronicа
fibrosa;
 Pulpitis chronicа
ulcerosa;
 Pulpitis chronic а
granulomatosa.
Pulpits of the primary teeth are
irreversible condition of the
pulp;
The pulp of primary teeth no
capacity for recovery due to
aging processes associated with
resorption.
Pulpits of the primary
teeth can be treated only
with mortale methods;
Most suitable is mortale
amputation.
Initially each pulp inflammation is a
chronic process;
Practically there is no acute pulpitis;
There are exacerbation of existing
chronic pulp inflammation;
The teeth pulp has good recreational
opportunities.
Reversible pulpitis
Closed
Asymptomatic
Open
Irreversible pulpitis
Closed:
Open
Symptomatic
morula
Blastocyst 6 days - a source of totipotent
embryonic stem cells
Moral problem - the blastocyst is not a human being?
Another more moral source for stem cells umbilical cord and placenta
Stem cells from extracted teeth – wise teeth
and other teeth in orthodontic reasons
New discovery - stem cells is even in the
pulp of deciduous teeth
The red coloration indicates the
presence of nestin;
Green staining demonstrated the
presence of actin
Pulp Therapy in the
Primary teeth
The treatment plan should be based
on specific diagnosed findings,
medical status and the child's
behavior, social status of the family.
 Reversible
- closed asymptomatic pulpitis;
 Large carious lesions without pulp symptom
"pain";
 Pulp symptom "pain" is:



Spontaneous pain;
Night pain;
Provoked pain - over 1 min;
 Occurrence
of pain while eating or irritation
in carious lesions still does not mean pulp
symptom "pain".
Large cavitated carious
lesions with:
1.Soften lighter or darker
carious dentin;
2. Lack of disclosure of the pulp
(pulpitis closed);
3. Cavitation affects closest
cusp;
4. The reserved portion is less
than ½ of the distance between
the tip of the cusp and fissure.
Carious process
covered the much
of the occlusal
surfaces;
There is no
disclosure of the
pulp.
But staining of the enamel is
in the vicinity of the tip of
the nearest cusps;
Incolored dentin is below ½
of the distance between the
bottom of the fissure and the
tip of the cusp - closed
pulpitis;
The size and
location of
cavitation
correspond of
pulpitis;
Absent disclosure;
 Large
carious
lesions with the
disclosure of the
pulp amongst
carious dentin;
 Open pulpitis.
Absence of pain symptoms:
• Absence of night pain;
• Absence of spontaneous pain;
Permissible pain symptoms
• pain of cold, sweet and pressure
at meals that disappear after
removing the challenge;
 Carious
lesion is close to the pulp, a thin and
partially demineralized dentin over the pulp
horn.
Not be taken due to the
subjective reaction of small
children.
After complete removal of a carious
dentin in the area of the enamel-dentin
junction began carefully removing the
carious dentin over the pulp
In the course of the work it is clear that
for the final elimination of this dentin
will be necessary disclosure of the pulp
When it comes to tooth decay, you may
remove the entire carious dentin over
the pulp, even in the area of pulp horn
without disclosing the pulp;
Over the pulp horn or at the bottom
remains thin, sometimes colored, but
durable and well mineralized dentin.
Spontaneous pain;
Nighttime pain;
Pain that occurs during a meal that does not go
away immediately after removal of the stimulus,
lasts and leads to the cessation of feeding, crying
and need for an analgetics.
Clinical findings
Large carious
lesions
with or without
a disclosure of
the pulp;
Large filling
with or without
a defects.
Spontaneous pain;
Nighttime pain;
Pain when chewing or at sweet and cold that does not
pass immediately after elimination of the stimulus;
Need to give an analgesic;
 Partially
or
completely
demineralized
dentin over the
pulp;
 Absence of dentin
over the pulp
horn.
There are quite rare;
Treating caries should
significantly reduce pilpitis;
Correct treatment of reversible
pulpitis should remove them.
of "National Association of
Pediatric Dentistry" for the
pulp treatment of primary
teeth
Treatment of reversible
pulp inflammation
The most appropriate
method - indirect pulp
capping!
Argument for the effectiveness of indirect
coverage
1.
Provides treatment of the majority of all primary teeth pulpitis.
2. The easiest;
3. Most atraumatic;
4. The best accepted of children;
5. No anesthesia is required;
6. Provides proven results;
7. Saves the vitality of the tooth;
8. Saves the functionality of the dentition;
9. Ensures correct physiological change.
First visit
First step:
Diagnosis – closed
asimptomatic pulpitis;
• The clinical features shows
softened carious dentin
without exposing the pulp;
• Symptom-free tooth – no
“pain symptom” .
1. Comprehensive medical history;
 2. Review of past and present dental history and
treatment, including current symptoms and chief
complaint;
 3. Subjective evaluation of the area associated with the
current symptoms/chief complaint by questioning the
child and parent on the location, intensity, duration,
stimulus, relief, and spontaneity;
 4. Objective extraoral examination as well as examination
of the intraoral soft and hard tissues;
 5. If obtainable, radiograph(s) to diagnose pulpitis or necrosis showing the involved tooth, furcation, periapical
area, and the surrounding bone;
 6. Clinical tests such as palpation, percussion, and
mobility

 All
caries is first cleared from the cavity
margins with a steel round bur running at a
slow speed:




From the cavity margins;
In gingival basis for interproximal defect (maybe
with excavators);
Dentin in the area under the enamel-dentine
border should be healthy, well-mineralized;
Enamel-dentin border must be clearly visible.
1.Gentle excavation than follows
on the pulpal floor, removing as
much of the softened dentine as
possible without exposing the
pulp.
2. A thin layer of setting calcium
hydroxide is then placed on the
cavity floor to destroy any
remaining microorganisms and to
promote the deposition of
reparative secondary dentine;
3. The indirect pulp cap was
covered with zinc oxide-eugenol
cement for 6-8 weeks;
4. Radiograph observation.
 First



step:
Radiographic review;
Observe dentin over the pulp - compared to the
first X-ray;
Expected results:


remineralization of demineralized dentin
and formation of new tertiary dentin;
The cavity was re-entered to
remove all remaining softened
dentine;
Periodic clinical and radiographic
review is then undertaken to
monitor the pulp response
 This
method is not recommended for
exposed pulp due to caries of primary teeth
from AAPD (2001, 2004, 2009).
 Not recommended by the British and IAPD.
 Therefore now this method is not
recommended for the treatment of primary
teeth.
Recommended method –
pulpotomiy
To preserve the vitality of the radicular pulp - in
primary teeth is difficult to apply and is not
currently recommended by any major worldwide
organization of pediatric dentistry;
To stimulate tissue regeneration and healing at the
site of the of amputation - in primary teeth
practically difficult to apply and is not
recommended;
To become root pulp in inert mass - real purpose of
the primary teeth and this is the easiest method.
Local analgesia;
Apply ruber dam wherever possible;
Remove caries and roof of the pulp chamber, remove
coronal pulp;
Apply medicament to radicular pulp on a cotton
pledget;
Remove the cotton pledget and check that there is no
exessive haemorrhage from the remaining pulpal tissue
 15,5%
Ferric sulfate - cotton pledget with
medicament placed over the radicular pulp
for 15 sec
 20% (1:5 solution) Formocresol (Buckly) for 5
min;
 МТА;
 Calcium hydroxid;
 Acting
on the surface of the radicular pulp;
 Agglutinate blood proteins and stop bleeding;
 It is suitable alternative to formocresol.
The oldest method with the
worst results;
In recent years revived but the
alternative to success is
extraction of the tooth (fully
eligible by the IAPD);
 Traditionally
been used;
 There have been some concerns about its
toxitivity, both locally and systemically;
 It is used a 1:5 concentration Backly
formocresol solution;
 It is hold 5 min in pulp chamber (1 min);
 Zinc oxid eugenol;
 Restore the crown, usually. With a stainlesssteel crown.
 Equal
parts formaldehyde and cresol;
 Concentration 1:5 is achieved when:




Three parts of glycerin;
One part of distilled water;
Mix in advance;
These four equal parts were mixed with one part
of the solution to Buckley.
Often results is
extraction;
 Glutaraldehyde:



Formaldehyde is a small molecule, a
glutaraldehyde - large;
Formaldehyde requires a long time for fixation of
the tissue - Glutaraldehyde act immediately.
The reaction of the glutaraldehyde can not be
reversed.
 Can
be an alternative for treatment.
Encouraging results;
Require monitoring and evidence in
primary teeth;
Require adapted technique;
Requires the cooperation of the child
and the parents;
Bad results in primary teeth;
Require monitoring and evidence in
primary teeth;
Require adapted technics and
cooperation of the child and the parents;
Alternative - extraction of the tooth.
 Mortal
pulpotomy
 Age
of the children is not suitable for
channel instruments;
 The roots are in resorption;
 Risk for permanent tooth bud;
 The method is easy to use;
 With sufficient reliability till time of
physiological tooth change.
 Desensibilisatio
pulpae
 Preparatio cavi dentis
 Amputatio pulpae
 Desinfectio pulpae
 Mumificatio
 Obturatio
1.
2.
There are two methods:
Method of Stransky – 3 visits;
Formalin-resorcin method – 2 visits.
 First


Diagnosis;
Caries removal


visit:
In order to protect the child from the pain does not
remove the entire caries, but only the one that:
 gives access to the pulp;
 is a gingival margin (in second class cavity).
Devitalization of teeth by arsenic trioxide
 Remove
devitalized arsenic trioxide;
 Cavity is formed, creating retention;
 All caries removal;
 Amputatio pulpae;
 Desinfectio pulpae;
 Mumificatio pulpae.
 Caries
removal from
cavity margins;
 Last caries removal is
from pulp roof.
 When
the bur passes
through the roof of
the chamber a “dip”
is felt;
 Once this is felt the
bur is not taken any
deeper but moved
sideways to remove
the roof of the pulp
chamber.
 Remove
coronal pulp
with a large round bur
or large excavators;
 Escavators are safer
to avoid perforation
in the furcation
region.
 With
small round bur
is removed the pulp
from the root in 1-2
mm.
Liquid-A
Liquid - B
Liquid –С
Rp/
Rp/
Rp/
Tricresoli 20.0 Resorcini 40,0 Natrii caustici
Formalini 60,0 Aq.destil. 50.0 Kalii caustici 4,0
M.D.S./A/
M.D.S. /B/
Aq.dest.
24,0
M.D.S./C/
Mix a paste of:
ZnO
eugenol
thymol
Dense texturecover with
powder Zno
Place the equal
drops of liquid A
and B close to
each other. Mix
at the time of
placing in the
pulp cavity
Apart from
them, on the
same plate is
placed a drop
of liquid C.
Dip the cotton
pledget in
mixed liquids A
and B and
place it in pulp
cavity for 1min.
Dried cotton
pledget with
liquid С put in
pulp chamber
for a second.
Fill the
periphery of the
root canals and
all pulp
chamber with
zinc oxid
eugenol and
thymol cement
for a provisional
filling.
Check for
complications.
If no – the
treatment
continues.
From zinc oxide Restoration.
thymol cement
is forming a
room for filling.
 Tricresolformalin




:
Lipid-soluble compound with the ability to cross
biological membranes;
Can to precipitate microbial cell proteins ;
Violates the lipid metabolism;
There are hydrophilic and hydrophobic groups.
 Has
antiseptic activity;
 Anti-inflammatory activity;
 The result of mixing trikresol-formalin-resorcin is a
bakelite;
 Potassium sodium hydroxide catalyzed process.
Formation of bakelite became in 2 hours.
 Before
the formation of bakelite started separating
paraformaldehyde:






disinfecting;
bactericidal;
dehydrates;
coagulate the protein;
mummification;
Impacting.
 Antiseptic:


Precipitated proteins of microbial cell;
Inhibits enzymes in microorganisms;
 Dehydrates.
Eugenol - clove oil;
 Thymol - oil of thyme herb;
 Include:

Phenols and aldehydes;
 biologically active substances;


Action:
Antiseptic;
 Antiinflammatory;
 Local anesthetic effect.

 First
visite – devitalisation.
 Second visit:





Caries removal;
Cavity preparation;
Pulp chamber roof removing;
Coronal pulp removing;
Radicular pulp (1-2 mm) removing
Of the sterile
plate is placed
a drop of 40%
formalin and
the tip of the
spatula with
resorcinol
crystals supersaturated
solution.
Dip the cotton
pledget and
place it in pulp
cavity for 2-5
min. With the
remaining
amount of the
solution and
zinc oxide stir a
hard paste.
Fill periphery of
the canals and
the base of the
pulp chamber,
with hard zincoxide cement
all pulp cavity,
then restoration
 Formalin





- 40%
Denature the proteins in MO;
Bactericidal action;
Virucidal;
Sporicidal;
Poorly penetrates deeply.



Affect microorganisms and toxic degradation;
Not interfere with the healing process in periodontal and
alveolar bone;
Antibacterial action to:



Str.haemolyticus
Str.Aureus
Bactericidal action:


Tricresol formalin - 51% sterility
Resorcin-formalin - 67% sterility
 Lack
of the catalyst;
 Slowly forming resin;
 In 24-48 hours is emitted formaldehyde
implements its action much longer;
 The treatment result is more reliable.
 Prevalent
chronic processes;
 Are developed mainly resorptive
periodontitis;
 Almost never observed proliferative
forms;
 Each exacerbation is associated with
stormy exudative inflammation and
abscess;
 The process easily becomes chronic and
forms a fistula.
 Required
antibiotic treatment;
 Hydration;
 Vitamins;
 Mechanical and chemical treatments of
tooth:

Providing outflow until the process becomes
chronic.
 In
additiontooth of treatment the fistula has
to be treated and;
 Processing to eliminate the epithelial lining
of the fistula;
 Stimulates fistula closing.
 It
is used resorcinol-formalin
method;


First visit - insert formalin-resorcinol;
Second visit

Paste of formalin-resorcinol and ZnO;
Hard zinc-oxide cement and restoration.
 First
primary molar –
pulpotomy;
 Second primary molar
– mortal pulpectomy



Pulpotomy;
Exise tha pulpal tissue
to the orifices of the
root canals;
Fill the pulp chamber
with a past.
 Hard
zinc oxid
cement;
 Filling.
 Pulpotomy.
1. Ensure easy and rapid correction of the problem;
2. Easily applicable to young children;
3. Easily applicable in children with anxiety;
4. Provide significant success of treatment;
5. Untimely extraction of primary teeth as a result of the methods is
minimized;
6. Provide adequate treatment against pathology, social status and
health education of children at home.
International Agency for Cancer Research
(IARC) in 2004 shall conclude: "There is
sufficient evidence that formaldehyde
causes nasopharyngeal cancer in humans"
There are strong, but still requiring study
evidence for the connection of
formaldehyde exposure, and leukemia;
 These
relationships have been observed in
chronic exposure to high doses observed in
industrial production, but not in children
treated by said methods;
 The current problem involves more the
production of these drugs than their
application;
 The difficulty comes from the impossibility of
obtaining these funds.
1. The success of methodologies;
2. Lack of any evidence of harm to the children or staff;
3. Pathology and health culture in our country;
4. Opportunities exist for acquisition of these funds;
5. Lack of reliable and successful competitor for alternative
methodologies;
6. Relatively small percentage of cases with irreversible or
reversible pulpitis open -