At permanent teeth in children
Of the permanent teeth
Young active odontoblasts;
Plenty of undifferentiated cells;
Little collagen fibers;
Rich ground substance;
Good blood supply - active microcirculation, elastic vascular walls, good shunt
system;
Plenty of unmyelinated nerve axons - fast reactivity
Blood supply to the tooth with
incomplete root development
Wide open root tip:
•Reduces tissue swelling;
•Favors venous flow;
•Removal of toxins;
A powerful vitality;
An opportunity for revitalization.
Favourable conditions
Powerful vitality and protection;
Possibility for removal of inflammatory products and
toxins;
Possibility for isolation and transformation into chronic
inflammation;
Possibility for a healing process and a real treatment.
The lack of composed apex does not stop inflammation;
Rapidly inflamatory transformation from one phase to
another;
Overcoming the growth zone leads to a direct involvement
of the surrounding bone;
Impossibility to use conventional methods of treatment.
Dental
decay
After 6th years
Pulpitis
After 8th years
Periodontitis
At the end of the
11th years.
The pulp involvement may be
developed earlier
During this period, root development is not completed
It takes 3 to 4 years after tooth eruption.
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This is the condition where the pulp is
inflamed and is actively responding to
irritant;
Symptoms include transient pain or
sensitivity resulting from many stimuli,
notably hot, cold, sweet, water;
This pulp can be recovered.
Reasons for early pulp involvement :
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Incomplete enamel mineralization - faster
dental decay development;
Thin dentinal layers, wide dentinal tubules rapidly pulp involvement;
Early permanent teeth eruption;
Rich carbohydrate diet;
Not established hygiene habits;
Weakening of the parental control.
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Initially is developed chronic pulp
inflammation;
In prevalence of pathogenic over protective
factors - the chronic pulpitis is exacerbated;
The teeth with incomplete root development
have increased protective capabilities - from
pulpal undifferentiated cells, stem cells,
powerful blood supply and innervation and
extremely vital growth area.
Classification of pulpitis of permanent teeth in children
Reversible pulpitis
Irreversible pulpitis
Open pulpitis
Closed pulpitis
Pulpitis asymptomatica clausa;
Pulpitis asymptomatica aperta;
Pulpitis symptomatica clausa;
Pulpitis symptomatica aperta;
1. Pain history;
2.Clinical Data;
3. Thermal tests;
4. Electric pulp tests.;
5.Radiographic Data;
6. Direct dentinal stimulation.
Pulp treatment of the permanent teeth with incomplete
root were divided into two groups:
Biological methods
•Indirect pulp treatment;
•Direct pulp treatment;
•Partial pulpotomy;
•Pulpotomy.
Endodontic treatment
The choice of treatment method
should be linked to the diagnosis
Biological methods are applicable
only in reversible pulpitis
Diagnostic protocol for
reversible pulpitis
(Closed and open)
Missing pulp symptom “pain”
• Missing spontaneous pain;
• Missing night pain;
Acceptable pain symptoms-thermal, chemical, and
mechanical irritants - pain of cold, sweet and pressure
when eating that disappear after removing the irritation.
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Large carious lesions (cavitated or uncavitated)
with established discoloration to, or over of the
half distance between the lowest point of the
fissure and the top of the nearest cusp;
Approximal lesion, which is covering a wider
area of the interproximal contact surface;
At closed asympotomatic reversible pulpitis –
big caries lesion with carious dentin over the
pulp;
At open reversible pulpitis - presence of
ulceration among carious dentin - Pulpal
exposure..
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With ice;
Chlorethyl,;
Hot gutta-percha;
At the the neck on a healthy enamel;
Thermal pain stimulation is called "provoked“.
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Place thermal stimuli on healthy enamel in
the tooth cervix;
Instant pain subsides immediately the
removal of stimulus means that the pulp is
healthy;
Retention of pain indicates an inflammation
of the pulp;
With the onset of the pain stimulus is
removed;
Measure the length of the resultant pain - a
criterion for the diagnosis and choice of
treatment method.
Diagnosis and the choice of the treatment method
based on evoked pain
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Retention of pain after removal of the tester
10-15 seconds to 30 seconds:
◦ Closed asymptomatic pulpitis - indirectly coverage '
◦ Open asymptomatic pulpitis - direct coverage;
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- From 30 seconds to 1 minute:
◦ Inflammation of the pulp in the majority of coronary
pulp;
◦ Values ​suitable for the application of pulpotomy.
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Electrical pulp tests are not valid in
permanent teeth without complete root
formation;
When the root development is incomplete
can be expected higher values ​in the test.
It is obligatory to determine the level of root
development;
Not showing inflammation of the pulp;
It is not always objective for the establishment of
demineralized dentin over the pulp;
Visible dentin over the pulp does not exclude pulpitis.
Not recommended;
It is not indicative of the diagnosis
between caries and pulpitis
Between caries and reversible pulpitis;
Between reversible and irreversible
pulpitis;
Between open and closed pulpits;
Exact diagnosis;
Selection of the most appropriate method;
Timeliness of treatment;
Proper implementation of the methodology.
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To maintain the integrity and health of the
teeth and their supporting tissues;
To maintain the vitality of the pulp of a tooth
affected by dental decay, traumatic injury, or
other causes;
Especially in young permanent teeth with
immature roots, the pulp is integral to
continue apexogenesis.
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Pulp preservation is a primary goal for
treatment of the young permanent dentition.
Primary Goals of Vital Pulp Therapy:
Dentin bridge
formation
Continuation of root development
Stimulation
Undifferentiated
mesenchymal cells
Pre existing
odontoblasts
Odontoblast like
cells
Reparative dentin
Reactionary dentin
Terciary dentin
Closed asimptomatic
pulpitis
Pulpitis asymptomatic
clausa
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Indirect pulp treatment is indicated in a
reversible pulpitis when the deepest carious
dentin is not removed to avoid a pulp
exposure;
The pulp is judged by clinical and
radiographic criteria to be vital and able to
heal from the carious insult.
Lack of spontaneous pain;
Lack of night pain;
Provoked pain is lasting less than 30 sec;
The crown of the tooth to be recoverable.
Methodology of application
(treatment in two visits)
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A procedure in which a material is placed on
a thin partition of remaining carious dentin,
that if removed, may expose the pulp
◦ Indirect pulp capping – stepwise excavation of
caries
◦ Indirect pulp capping without re-entry and farther
excavation
Stepwise excavation of
caries:
Technique in which dental decay is removed in
increments in two or three appointments over a few
months to a year rather than removing the caries in
one sitting (indeep carious lesions)
Each time dental decay is removed glass ionomer
base is placed which may contribute to
mineralization, followed by a well sealing temporary
restoration.
classical method
Clinically established a deep carious defect with the softened carious
dentin;
Cavity is formed;
Clean carious dentin of its walls;
Clean the majority of carious dentin on the bottom of the cavity;
Remains the demineralized dentin over the pulp, which in principle
should be removed.
Progressive carious
lesions towards the
pulp;
If you remove the
whole caries, thr pulp
will be disclosed.
Infected dentin - demineralized dentin
containing microorganisms and their
toxins;
Affected dentin - demineralized
dentin, in which there are no microorganisms, but only their toxins.
Affected dentin - meets the second and third zone
of dentine caries cone - no bacteria, demineralized
dentin, but not denatured:
•Can be remineralized;
•It is not necessary to be removed;
Infected dentin - the fourth and fifth zone of dentine
caries cone - there are bacteria and the collagen is
denatured irreversibly.
•Should be removed.
Clinical strategy for the caries removal
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Dentin, which is softened, which is peeling, in
which the probe may penetrate - to be
removed;
Complete removal of carious dentin only by
dentino-enamel border;
Carefully remove the carious dentin over the
pulp roof.
With a large round burs and low speed;
With very little pressure;
Upon reaching near pulp - careful use of excavators;
After carefully removing the softened dentin, cleaning stops;
It is not recommended for the presence of staining carious
dentine, since this requires aggressive cleaning.
G.V. Black, 1908
“The divorce between dental practice and research in the
field of caries pathology, which existed in the past, is an
anomaly that should not exist anymore. This is a trend
that obviously converted dentists in the craftsmen. "
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When creating the methodology - two visits:
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The first visit - is remains afflicted dentin;
Cover with Ca (OH)2;
Wait two months;
After 2 months remove restoration, excavate
remaining caries, restoration.
Now it is known that affected dentin can be
leaved and restoration can be done.
Now we know that if we leave affected
dentin – we treat like a caries in one
visit;
Therefore, in indirect treatment we can
leave a large amount of carious dentin
to the second visit.
methodology
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Remove entirely carious dentin from dentinenamel border;
Carefully remove the softened infected dentin
by the cavity walls;
The infected dentin over the pulp is removed
step by step, very carefully and can leave a
large amount of carious dentin.
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Wash and dry;
Bottom of the cavity is covered with calcium
hydroxide:
◦ Thickness - 0.5 - 1 mm.
◦ The entire cavity is filled with a paste of ZOE;
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Make a radiograph, which will serve as the
control;
Examine the vitality of the tooth that will
serve as a control;
Tooth left thus for 6-8 weeks.
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Vitality test;
Compare with baseline data;
Radiograph for control of:
◦ Formation of terciary dentin;
◦ Remineralization of remained demineralized
dentin.
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If the results are good, the treatment ends at
this visit;
Remove the ZOE past;
Remove demneralized dentin;
Carefully preserving remineralized dentin.
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Wash and dry the cavity;
Cover the bottom of the cavity with calcium
hydroxsid;
Restoration.
Case of recurrent caries on
the first permanent molars;
Missing spontaneous and
night pain;
Provoked pain is 15
seconds;
Indirect treatment
After one year:
Formed a secdentin;
The pulp is reduced
by volume;
No periapical
changes;
The tooth is vital.
11 year old girl;
Recurrent caries under a
restoration;
Closed asymptomatic
pulpitis;
Indirect treatment
New dentin
is formed;
Tooth is
vital.
ncreased dentin layer;
Reduced pulp chamber;
Normal lamina dura;
Preserved vitality.
The first year is monitored at 3 months;
The second year of six months;
Traces the:
•X-ray:
•Presence of new dentin formation;
Completion of root development.
Vitality of the tooth.
Two years after treatment,
the tooth is vital;
If root development has
continued successfully.
History:
• The toot is
asymptomatic;
• Provoced pain for
10 sec
• Carious lesion;
Clinics:
• No disclosure pulp;
• No pain on percussion;
• Normal gingiva;
• Normal color of the
tooth.
Indirect treatment
Small occlusal cavitation with great coloration around it
showing the development of large carious lesion
There are no periapical changes
suggestive of irreversible pulpitis or
pulp necrosis;
Visible carious dentin advanced close to
the pulp, which indicates serious risk to
disclosing it in the cleaning process.
Radiografic data
Deep caries lesion and normal periapical
structures
First visit
After cavity access, initial removal
of soft carious dentin with
excavator.
Mechanical removal of carious dentin
Demineralized dentin remains over pulp,
which means that its removal will reveal the
pulp
Indirect pulp treatment
Place a thin layer of calcium hydroxide
over demineralised dentine
Provisional restoration
It is used GIC
Second visit after 2 months
Visible remineralization of the demineralized dentin and
secondary dentin formation. There are no periapical
changes.
Treatment
Caries removal of the unmineralized dentin
New thin layer of calcium hydroxide
Place a thin layer of glass ionomer
cement. Can be covered entirely with
glass ionomer cement.
Restoration
Radiograpg
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Ca(OH)2 – Ph - 12,3 – 12,38
Ca(OH)2 + H2O = PH - 12,75
Ca(OH)2 +serum = PH - 9,4
Alkalizing;
Dehydration;
Bactericidal;
Lysed necrotic tissue;
Biologically.
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Affected acidosis normalizes the tissue;
Dehydration reduces tissue edema;
Increases metabolic activity;
Corrected and normalized ratio O2/CO2;
Removing the source of irritation;
Conducive to the healing process;
Stimulates the function of fibroblasts and
odontoblasts.
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Ca(OH)2 paste is degraded to Ca + 2OH;
Ca binds rapidly with O2 to form CaO:
CaO quickly aspirate the water from the
tissue fluid by forming new portion of
Ca(OH)2;
Quickly occupied all the liquid;
Reduced pulp tissue pressure.
Ca (OH)2 releases a OH groups
which are lysed existing
necrotic tissue;
• The necrotic tissue is transformed into water and
carbon dioxide (toxic products);
• They are absorbed by physical diffusion.
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After complete consumption of CO2, CaCO3
begins to be deposited on:
- Internal surface of the dentin;
- Fibrous tissue.
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Destruction of the remaining MO;
Stop of the inflammation;
Remineralization of remained demineralized
dentin;
Formation of protective terciary dentin;
Preserving the vitality of the pulp.
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Exacerbation of inflammation:
◦ Due to improper diagnosis;
◦ By inappropriate application of the methodology.
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Necrosis of the pulp:
◦ Early - up to 2 years;
◦ Later - after two years;
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Calcification of the pulp.
Open reversible pulpitis;
Open crown fractures
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The treatment of an exposed vital pulp by
sealing the pulpal wound with a dental
materials placed directly over exposure site
to facilitate the formation of reparative
dentine end maintenance the vital pulp.
Criteria for use of direct coverage in open
asymptomatic pulpitis
After carious removal disclosure is clearly red;
Have bleeding controlled;
Disclosure is not greater than one millimeter in diameter;
Disclosure is not in the cervical area;
Disclosure before 24 hours;
The sizes of disclosure are not larger than
1 mm in diameter;
Disclosure not in the cervical area.
To influence the inflammatory process;
To close the wound through the formation
of calcified fibrous dentine bridge
To maintain the vitality of the pulp;
Method application treatment in one visit
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Radiography - control;
Examine vitality - control;
Place anesthesia;
Remove all carious dentin;
Wash disclosure with physiological saline;
Dry;
Place non-hardening calcium hydroxide on
disclosure and neighboring dentin;
Place the glass yonomer
cement;
Place the final obturation.
In fractured teeth with pulp disclosure
restoration is made lower than the
occlusion;
Is avoided chewing additional trauma.
Crown fracture with pulp
disclosure than 1 mm;
The bleeding has
stopped;
Direct coating the wound
and restoration.
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Deep carious
lesion with
disclosure of the
pulp of not more
than 1 mm in
diameter.
Control the vitality of the tooth;
Radiographic control:
•Formation of calcified fibrous structure into
disclosure;
•Reparative dentin formation around disclosure;
•Completion of root formation.
The first year – every 3 month
The second year – every 6 month.
Inflammation is stopped;
Recovery of the pulp biological activity ;
Fibroblasts stimulation for fibrous membrane formation
under disclosure.
Calcification of the fibrous membrane.
Stimulation of living odontoblasts around
disclosure to production of reparative dentin;
Preserving the vitality of the pulp;
Completing the root apex formation.
Exacerbation of
inflammation:
•When misdiagnosed;
•Incorrect application of the methodology.
Pulp necrosis:
•Early - up to 2 years;
calcifications:
•In the coronal pulp;
•Late - over two years.
•In the root pulp.
Partially biological method
Open reversible pulpitis with disclosure greater than one
millimeter in diameter
Open reversible pulpitis with disclosure in the cervical area;
• Detecting fracture of the pulp of greater than 1 mm in diameter, and, by 24
hours after injury;
• Fracture with disclosure in the cervical area before 24 hours after trauma pulpotomiya;
Take into account the degree of root development - to
attempt to conduct pulpotomiy even if only ½ built root.
With the removal of crown pulp to remove
inflammation;
To maintain the vitality of the radicular
pulp;
To ensure completion of the root apex .
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Provoked pain is about 1 min;
Spontaneous pain is short with long periods
without pain;
No night pain;
The crown of the tooth is recoverable;
There are at least two thirds of the root;
There is no internal root resorption.
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No abscess or fistula;
The blode after pulpotomiy be red;
Hemorrhage is controlled (2-5min)
Missing smell.
One visite
• Wanted internal root resorption;
Radiograpfic
control:
• Determine the extent of root
development:
• Serves as a criterion for the success of
treatment;
• Serve for comparison after treatment.
Pulp vitality
tests:
•Criterion for the success of
treatment;
•Initial base for comparison
Traumatic disclosure of the
pulp greater than 1 mm;
The revelation occurred
before 1 hour;
Bleeding is controlled.
Healing pulp wound
Formed calcified
fibrous barrier under
calcium hydroxide.
Fracture with pulp
disclosure over
1mm
Vital pulpotomy
Formation of calcified
fibrous bridge over
the wound surface
Continuing
apexigenesis
Fracture of the crown of a
tooth with incomplete root
development;
Disclosure is 3-4 mm;
Vital pulpotomiya
Formation of
calcified bridge;
Thickening of the
walls of the root;
Continuing
apexigenesis
Anesthesia;
Cavity is formed;
Clean all caries dentin;
Cut tectum cavae pulpae;
Crown pulp is removed;
Remove 1 mm from the root pulp.
The wound was washed with saline, or boiled water;
After stopping the bleeding is dried;
On the wound surface is placed non-hardening calcium hydroxide
without pressure;
GIC without pressure;
Place the final restorationb.
Radiographic
control:
Formation of
fibrous calcified
barrier under the
wound surface;
Continuation of
root development;
Formation of
calcifications.
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Subjective symptoms of the patient;
Follow up:
◦ The first year of 3 months;
◦ Second year of 6 months
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Termination of pulp inflammation;
Restoration of the biological functions of the
root pulp;
Preserving the vitality of the root pulp;
Completing the root and close the apex;
Providing complete function of the tooth.
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Exacerbation of inflammation:
When misdiagnosed;
Incorrect application of treatment methods.
Necrosis of the root pulp:
Early - up to 2 years;
Later - after two years.
Calcifications in the root pulp
and subsequent necrosis;
Obliterating the root canal.
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When necrosis and incomplete root canal
treatment:
◦ Implementation of methodologies for apeksgenezis;
◦ Failure - for apeksfikatsio.
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When necrosis and complete root
development:
◦ Emergency pulpectomy;
◦ Routine root therapy.
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In incomplete root development:
Apexgenesis;
Apexficatio.
When completed root development:
pulpectomy;
Routine root therapy.