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Self‐Study Questions
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COMPLEX PULP THERAPY
1. What are the treatment objectives for a complicated crown fracture?
2. According to Cvek, what are the pulpal changes
resulting from a traumatic pulp exposure?
3. What are the advantages of using NaOCl to
control pulpal hemorrhage during a pulpotomy
procedure?
4. What are the advantages of a partial pulpotomy
over a pulpectomy for treatment of a complicated
crown fracture?
5. What are the most commonly used pulp dressing
materials in partial pulpotomy, and what are their
properties?
Answers are located at the end of the case
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Self‐Study Answers
1. To maintain pulp vitality and restore normal
esthetics and function
2. Cvek has shown that with pulp exposures
resulting from traumatic injuries, regardless of the
size of the exposure or the amount of lapsed time,
pulpal changes are characterized by a proliferative
response with inflammation extending only a few
millimeters into the pulp (Cvek 1994)
3. NaOCl, when placed on the exposure site, causes
hemostasis, has a beneficial effect of killing bacteria,
and does not damage the pulpal cells
Bibliography andAdditional Reading
Camp JH, Fuks AB. 2006. Pediatric endodontics: endodontic
treatment for the primary and young permanent dentition.
In: Pathways of the Pulp, 9th edition. Cohen S, Hargreaves
KM (eds). St Louis: Mosby Elsevier. Chapter22.
Cvek M. 1994. Endodontic management of traumatized teeth.
In: Textbook and Color Atlas of Traumatic Injuries to the
Teeth, 3rd edition. Andreasen JO, Andreasen FM (eds).
Copenhagen: Munksgaard.
Fuks AB, Heling I, Nuni E. 2012. Pulp therapy for the young
permanent dentition. In: Pediatric Dentistry, Infancy Through
Adolescence, 5
Louis: Elsevier. pp. 490–502.
th
edition. Casamassimo PS et al. (eds). St
4. Partial pulpotomy allows for the preservation of
cell‐rich coronal pulp, increases the healing potential
due to preservation of the pulp, allows the
physiologic apposition of cervical dentin, obviates
the need for root canal therapy, and preserves the
natural color and translucency
5. Ca(OH)2 and MTA. Both stimulate the healing of
the pulp and the formation of a dentin bridge
Fuks AB, Nuni E. 2019. Pulp therapy for the young permanent
dentition. In: Pediatric Dentistry: Infancy through
Adolescence, 6th edition. Nowak A, etal. (eds). Philadelphia:
Elsevier. p. 482.
Geneser MK, Owais A. Pulp therapy in primary and young per-
manent teeth. In: The Handbook of Pediatric Dentistry, 5
edition. Nowak AJ, Casamassimo PS (eds). Chicago:
American Academy of Pediatric Dentistry. pp. 138–56.
Kupietzky A, Holan G. 2003. Treatment of crown fractures with
pulp exposure in primary incisors. Pediatr Dent 25:241–48.
Ram D, Holan G. 1994. Partial pulpotomy in a traumatized
primary incisor with pulp exposure: case report. Pediatr
Dent 16:46–8.
th
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COMPLEX PULP THERAPY
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Case 3
Cervical Pulpotomy inCariously Exposed PrimaryMolars
Uses toothpaste containing fluoride
A
Figure 3.3.1 (A, B) Facial photographs.
A. Presenting Patient
• Five‐year‐, six‐month‐old Hispanic female
(Figure3.3.1)
• New patient presenting as an emergency
B. Chief Complaint
• Mother confirmed the patient’s complaint of pain in
the mandibular left quadrant while eating; it subsides
after a few minutes without taking analgesics
C. Social History
•
Fourth of six children
• Middle socioeconomic status
D. Medical History
• Review of medical history revealed no significant
findings, no known drug or food allergies, no
medications, vaccinations are up to date
E. Medical Consult
• Not applicable
F. Dental History
• No dental home
• Eating habits include a low‐protein, high‐carbohydrate diet
• Poor oral hygiene, brushes without supervision
B
•
• Optimal water fluoridation levels
•
No history of trauma
• Seven‐day history of pain without history of swelling
or fever
G. Extraoral Exam
• No significant findings
H. Intraoral Exam
Soft Tissues
• Generalized gingivitis
Hard Tissues
• No significant findings
Occlusal Evaluation ofPrimary Dentition
• Mesial step molars and class I canines
Dental Exam
• Extensive plaque accumulation
• Several teeth with extensive carious lesions: maxillary
first primary molars, mandibular left first primary
molars, maxillary lateral and central incisors
Diagnostic Tools
I.
• Periapical radiograph of the maxillary incisors
(Figure3.3.2)
• Two bitewings (Figure3.3.3)
• Unable to obtain posterior periapical radiographs due
to uncooperative behavior
• Radiographic lesions on maxillary first and second
primary molars, maxillary lateral and central incisors,
left mandibular first primary molar, mandibular primary
canines, and mandibular right first and second
primary molars
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Figure 3.3.2 Periapical radiograph of the maxillary incisor.
•
Explanation to the mother of the importance of
maintaining the primary molars for proper
occlusion
• Comprehensive treatment of other carious lesions
• Follow‐up care including:
Postoperative and home care instructions
Caries prevention plan
Appropriate recall plan
M. Radiographic Follow‐Up
• Postoperative bitewing radiographs (Figure3.3.4)
obtained six months post‐treatment show restoration
in good repair
A
Figure 3.3.3 Bitewing radiographs. (A) Right bitewing
radiograph; (B) left bitewing radiograph.
B
J. Differential Diagnosis
• Deep carious lesions
• Reversible pulp inflammation
• Irreversible pulp inflammation
• Partial pulp necrosis
• Total pulp necrosis
K. Diagnosis andProblem List
Diagnosis
•
Based on the history of pain, clinical examination, and
radiographic findings, the most probable diagnosis for
the left mandibular first primary molar isa deep
carious lesion with reversible pulp inflammation
Problem List
• Several untreated carious lesions
• High caries risk due to several factors (cariogenic
diet, poor oral hygiene with extensive plaque
accumulation)
• Lack of dental home
L. Comprehensive Treatment Plan
• Treatment of the maxillary right and left primary first
molars and the mandibular left primary first molar
FUNDAMENTAL POINT 1
Pulpotomy InPrimary Teeth
Treatment Objectives
• Eradicate potential for infection
• Maintain tooth in a quiescent state
• Preserve space for underlying permanent tooth
• Retain primary tooth if permanent tooth is
congenitally absent
Indications foraPulpotomy
• Some deep carious lesions even without pulp
exposure
• Carious or traumatic pulp exposure with transitory
thermal and/or chemical stimulated pain
• No more than physiologic mobility
• Normal soft tissues
• No percussion sensitivity (except in cases of
food impaction)
• Intact continuous ligament space
• Intact periapical and/or furcation bone
Confounding Factors inDiagnosis of
Pulp Status
• Pulp bleeding color is an indicator of clinical and
histohematologic status of primary teeth
(Aaminabadi etal. 2017)
• Excessive bleeding is strongly correlated with
degenerative changes
• One‐third of teeth with carious pulp exposures
have “normal” pulps
• One‐third of teeth with deep caries with no pulp
exposures have “abnormal” pulps
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A
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Figure 3.3.4 Postoperative bitewing radiographs. (A)
Postoperative right bitewing radiograph; (B) postoperative left
bitewing radiograph.
B
N. Prognosis andDiscussion
• The pulpotomy procedure is based on the rationale
that the radicular pulp tissue is healthy or is capable
of healing after surgical amputation of the affected or
infected coronal pulp. The presence of any signs or
symptoms of inflammation extending beyond the
coronal pulp is a contraindication for a pulpotomy
COMPLEX PULP THERAPY
•
The ideal dressing material for the radicular pulp
should:
Be bactericidal
Promote healing of the radicular pulp
Not interfere with the physiologic process of root
resorption
• A good deal of controversy surrounds the issue of
pulpotomy agents, and, unfortunately, the “ideal”
pulp dressing material has not yet been identified.
Formocresol (Buckley’s solution: formaldehyde,
cresol, glycerol, and water) was a commonly used
pulp dressing material
• Clinical and radiographic studies have demonstrated
that formocresol pulpotomies have success rates up
to 97%. Although many studies have reported the
clinical success of formocresol pulpotomies, an
increasing body of literature has questioned the use
of formocresol (Fuks etal. 2019; Coll et al. 2017)
BACKGROUND INFORMATION 1
Pulpotomy Technique forPrimary Teeth
Technique
• Excavate caries, amputate coronal pulp, achieve
hemostasis, treat radicular pulp with medicament,
restore with permanent restoration
Formocresol (FC) Pulpotomy
• Method of action: tissue fixation
• Histological zones in FC‐treated radicular pulp
Acidophilic zone: fixation (coronal)
Pale staining zone: atrophy (middle)
Broad zone of inflammatory cells (apical)
• Bactericidal
• Acceptable outcome is 62–97%
• No dentinal bridging, but calcific changes evident
• Persistent chronic inflammation
• Small risk of succedaneous tooth damage
• Exfoliation accelerated
• Cellular toxicity
• Immune sensitization risk
• Humoral and cell‐mediated responses:
controversial
• Mutagenic and carcinogenic potential: controversial
Ferric Sulfate (FS)
• 15.5% in aqueous base, pH = 1
• Method of action: hemostatic, denatures protein,
and forms ferric ion complex that occludes cut
blood vessels
• Shorter application time than FC (10–15 seconds)
• Equivalent outcome to FC
• Self‐limiting internal resorption reported
Mineral Trioxide Aggregate (MTA)
• Method of action: mineralization, dental cement
with discrete crystals and amorphous structure,
pH= 12.5
• Pulp canal obliteration common
• Equivalent outcome to FC
• Good clinical results
O. Common Complications andAlternative
Treatment Plans
• Unsuccessful pulpotomy in a primary molar might
result in internal resorption progressing into the
bone, an interradicular pathological lesion,
and/or a periapical abscess, with or without a
parulis.In most of these situations, the teeth must
be extracted
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Self‐Study Questions
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COMPLEX PULP THERAPY
1. Which teeth are good candidates for pulpotomy?
2. What are the contraindications for a pulpotomy?
3. What are the objectives of a pulpotomy?
4. What are the complications of a pulpotomy
failure in a primary molar?
5. What are the desirable characteristics of an ideal
pulp dressing?
Answers are located at the end of the case
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Self‐Study Answers
1. Teeth with carious or traumatic pulp exposure
with transitory thermal and/or chemical stimulated
pain, with physiologic mobility, normal soft tissues,
no percussion sensitivity (except in cases of food
impaction), intact continuous ligament space, and
intact periapical and/or furcation bone
2. Teeth with carious or traumatic pulp exposure
with spontaneous pain, persistent thermal and/or
chemical stimulated pain, pathologic mobility, inflamed
soft tissues, parulis, percussion sensitivity, widened
and/or discontinuous ligament space, furcation and/or
periapical radiolucencies, external and/or progressive
internal resorption, dystrophic intrapulpal calcifications,
less than one‐third physiologic root resorption
Bibliography andAdditional Reading
Aaminabadi NA, etal. 2017. Pulp bleeding color is an indicator
of clinical and histohematologic status of primary teeth.
ClinOral Invest 21:1831–41.
Coll JA, etal. 2017. Primary tooth vital pulp therapy: a system-
atic review and meta‐analysis. Pediatr Dent 39(1):16–123.
Dhar V, Marghalani AA, Crystal YO etal. 2017. Use of vital pulp
therapies in primary teeth with deep caries lesions. Pediatr
Dent 39(5):E146–E159.
3. To maintain tooth vitality and to cause no harm
to the succedaneous tooth
4. Unsuccessful pulpotomy in a primary molar
might result in internal resorption progressing into
the bone, in an interradicular pathological lesion,
and/or a periapical abscess, with or without a
parulis
5. The ideal dressing material for the radicular pulp
should be bactericidal, harmless to the pulp and
surrounding structures, promote healing of the
radicular pulp, and not interfere with the physiologic
process of root resorption
Fuks A, Kupietzky A, Guelmann M. 2019. Pulp therapy for the
primary dentition. In: Pediatric Dentistry: Infancy through
Adolescence, 6th edition. Nowak A, etal. (eds). Philadelphia:
Elsevier. p. 329.
Geneser MK, Owais A. 2018. Pulp therapy in primary and
young permanent teeth. In: The Handbook of Pediatric
Dentistry, 5th edition. Nowak AJ, Casamassimo PS
(eds). Chicago: American Academy of Pediatric Dentistry.
pp. 138–56.
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Case 4
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Root Canal Treatment in a Primary Molar
Medical Consult
E.
• Not applicable
F.
Dental History
• No dental home
• Was taken for the first time to a dental office for an
emergency visit the day before and antibiotics
wereprescribed
• Poor oral hygiene habits
• Low‐protein, high‐carbohydrate diet
• Uses toothpaste containing fluoride
• Optimal water fluoridation levels
• No history of trauma
COMPLEX PULP THERAPY
Figure 3.4.1 Facial photograph.
A. Presenting Patient
• Five‐year‐, two‐month‐old Hispanic female (Figure3.4.1)
• New patient presenting as an emergency
B. Chief Complaint
• Mother stated that the child “had excruciating pain
awaking her from sleep last night, and the gums close
to the right lower back tooth were swollen andred”
C. Social History
• Youngest of three children
• Lower socioeconomic status
D. Medical History
• Review of medical history revealed congenital
deafness, no known drug or food allergies, no
medications, vaccinations up to date
G. Extraoral Exam
• No significant findings
H. Intraoral Exam
Soft Tissues
• Swelling and redness around mandibular right primary
second molar
Hard Tissues
No significant findings
•
Occlusal Evaluation ofPrimary Occlusion
• Vertical terminal plane, flush occlusal pattern
Dental Exam
• Moderate plaque accumulation
• Several teeth with extensive carious lesions
I. Diagnostic Tools
• Two bitewing radiographs
• Anterior periapical (maxillary) radiograph
• Periapical radiograph shows extensive pathological
radiolucency in the interradicular area of the
mandibular right second primary molar
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J. Differential Diagnosis
• Acute dentoalveolar abscess
• Periodontal abscess
• Periapical granuloma
• Dentigerous cyst
• Radicular cyst
K. Diagnosis andProblem List
Diagnosis
• Based on the history of pain, the clinical
examination,and the radiographic findings, the
mostprobable dental diagnosis is acute
dentoalveolarabscess in themandibular right
secondprimary molar
• Extensive carious lesions in other primary teeth
Problem List
• High caries risk due to several factors (cariogenic
diet, poor oral hygiene with moderate toextensive
plaque accumulation, special health careneeds)
• Several untreated carious lesions
• Lack of a dental home
• Extremely apprehensive
• Deafness
L. Comprehensive Treatment Plan
• Urgent treatment of abscessed mandibular right primary
second molar with pulpectomy and stainless steel crown
• Explanation to the mother of the importance of
maintaining a second primary molar, particularly prior
to the eruption of the first permanent molar for space
maintenance
• Behavioral management considerations (consider
using nitrous oxide)
• Comprehensive treatment of other carious lesions
Follow‐up care including:
•
Postoperative and home care instructions
Prevention plan
Recall plan, including any necessary consultations
(orthodontic, endodontic, oral surgery,etc.)
M. Radiographic Follow‐Up
• Multiple bitewing radiographs at follow‐up visits show
successful root canal treatment (RCT) and stainless
steel crown restoration followed by eruption of
premolar in appropriate occlusion (Figures3.4.2–3.4.5)
N. Prognosis andDiscussion
• The goal of pulpectomy is to maintain primary teeth
that would otherwise be lost. The pulpectomy
Figure 3.4.2 Radiograph, immediately post-root canal
treatment. Notice extensive pathologic radiolucent
interradicular area (see arrow).
Figure 3.4.3 Fifteen months postoperative radiograph. Notice
interradicular area has healed with bone apposition (see arrow).
Figure 3.4.4 Four years and eight months post‐root canal
treatment showing treatment success.
Figure 3.4.5 Radiograph showing fully erupted premolar in
appropriate occlusion.
procedure is indicated in teeth that show evidence of
chronic inflammation or necrosis in the radicular pulp, in
teeth with carious exposure in which the radicular pulp
exhibits clinical signs of hyperemia following coronal
pulp amputation, or in teeth with evidence of necrosis
of the radicular pulp, with or without caries involvement
• Conversely, pulpectomy is contraindicated in cases of
infection involving the crypt of the succedaneous tooth,
in teeth with nonrestorable crowns, with perforation of
the pulpal floor, with internal resorption perforating into
the underlying bone, and with external resorption of
more than one‐third of the root (Moskovitz etal. 2005)
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