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Pulp therapy for the young permanent dentition

The dr said that we have a full lecture in endodontics talking about pulp therapy for permanent dentition, but in the lecture we will talk about pulp therapy for young permanent teeth which mean permanent teeth in children especially the 6s and the 7s teeth, But in the adult its different. For example : in child or adolescent , if we do PRR and we reach the dentine we have to place a liner in the cavity but in the adult we have to estimate that the cavity is deep so its subjective decision nobody can say if we reach 3 or 5 or 6 mm we have to place a liner. The types of pulp therapy techniques that we apply for these young permanent teeth differ from those for adult permanent teeth by this technique less invasive than the adult so we can go through these technique in the beginning for adult tooth . So the pulp in permanent teeth is necessary for dentine formation and loss of vitality in these young teeth before root completion leaves thin, weak root prone to fracture. The thing we should know that the dentine in these teeth still thin however its erupted, so the dentine has not reach the full thickness, why this dentine is important ? Because this dentine will give the tooth its strength and prevent caries from reaching the pulp. Classification of pulp therapy for young permanent teeth : 1. Apexogenesis: vital pulp therapy procedures. 2. Apexification : non-vital pulp therapy procedures used with RCT which we used for necrotic pulp tissue teeth. In modern dentistry this classification could be not enough because nowadays we can do apexfication in RCT by the MTA material which close the apex of then we fill it with GP and finish the treatment in 1 visit.

Again: Apexogenesis : vital pulp therapy procedures performed to encourage physiological development and formation of the root apex so by the prevention of the dentine the root apex will continue formation by stimulation of the odontoblast. The Aim: to promote root development and apical closure. Goals of apexogenesis : 1.Sustaining of viable HERS (Hertwings epithelial root sheet ) and this HERS is responsible for root formation which is important in crown/ root ratio (C-R ratio ), imagine that the tooth with normal crown length and abnormal root length this will affect the stability of the tooth so it will affect the occlusion which may result in occlusion trauma . 2.Maintaining pulp vitality, allowing odontoblast to lay down dentine which makes the root thicker and less chance of fracture. 3. promoting root end closure to fill the canal with GP . 4.Generating a dentine bridge at site of pulpotomy. The techniques: 1-indirect pulp cap: its the same procedure we apply for the primary teeth and used when : we have a deep caries and start excavation from the walls and then the walls until we reach the floor so we will end up with pulp exposure of immature root apex . - trauma class II fracture and immature apex, this year. thwe will discuss in 5 - Asymptomatic tooth: means there is no symptoms of irreversible pulpitis or necrotic pulp but its normal to have reversible pulpitis symptoms. - No abnormal radiographic change changes so we still need RG at the beginning. -

What we mean by changes? We dont need periodontal space widening or per apical radiolucent area or bone and root resorption.. etc. Now the indirect pulp cap procedures : infected dentine should be removed the affected dentine will remineralise and the odontoblasts will form reparative dentine by the applying material thus avoiding the pulp exposure. Later they make it by step-wise excavation, they remove as much they can and leave a single layer ,then placing calcium hydroxide and filling and get the patient to come back after 3 month to open the tooth again hoping that we have a reparative dentine then remove the single layer that we left because now we have a dentine bridge formed. Tooth maybe re-entered following procedure to remove remaining caries, So clinician differ on whether this should single visit or 2 visits (open it).the dr prefer 1 visit with good coronal seal ( meaning put a crown immediately).

IPC Rationale: the tooth that has carious lesion near pulp,biocompatible material placed over layer of remaining carious dentine to prevent pulp exposure and stimulate pulp tissue healing repair.

Indications: - normal pulp - reversible pulpitis (clinical &RG criteria) Material that we use in IPC: 1. Calcium hydroxide (always the material that has been used) 2. ZOE (acceptable,becuse it has a problem which is the coronal seal but you can place a layer of it and then cover it with GI) 3. GIC (excellent because it an adhesive material) 4. RMGI (the dr`s choice,also an adhesive material and it has a properties of composite and GIC) 5. The final restoration which is the SSC in posterior and AECR in anterior teeth The Succes rate : 74% to 99% of cases (depended on the coronal seal) IPC Objectives: 1. 2. 3. 4. Restorative material seal dentin from oral environment Vitality of tooth should be preserved No pos treatment signs/symptoms (pain,sensitivity) No RG evidence of external or internal RR or pathologic changes 5. Teeth with immature root apex&continuos root development

2. Direct pulp capping Direct pulp capping : is the application of medicament or dressing to the exposed pulp in an attempt to preserve the vitality. when small exposure of the pulp is encountered during cavity preparation, and the hemorrhage starts so we need first to stop the bleeding then we quickly cap the pulp tissue either by Calcium Hydroxide or MTA, and then place the restoration that seal the

tooth, usually we place GIC then composite on top or a crown on posterior teeth. IMP. NOTE: we never place our Calcium Hydroxide unless we are sure that you stopped the hemorrhage, if there is any hemorrhage and you put the Calcium Hydroxide you will not get a good results, its like you are starting a fire inside the pulp, you are inducing the undifferentiated mesenchymal cells to form odontocalsts and start resorbing the pulp and cause internal root resorbtion, so its very important to arrest the bleeding.

Indications: There should be minimal exposure to the pulp like : 1- mechanical exposure of the pulp 2- traumatic exposure of the pulp in all cases the pulp should be normal. Materials: 1. Now the first material that we used in such case is Calcium Hydroxide, am not going to explain in details about it because you should know it by heart. 2. is MTA ( Mineral Trioxide Aggregate ).(shaggob w 3allosh ento 3arfeen 3anno:P) When they made histological evaluation to MTA they found that it causes less inflammation, and induce the formation of dentin bridge, the MTA is a material similar to concrete ( ) , its formed of many minerals & salts like aluminum, iron oxide, carbon, it was

developed by a Turkish dentist called Mahmoud Tarabenjad.(kan ymathel m3 lamees w ya7ya:D) as we said MTA is similar to concrete, for that its so hard to drill through it thats why they use it in pulp capping, preparation, and many uses nowadays. MTA use to be grayish in color just like amalgam, and now they have developed other versions that are whiter in color, because when we want to use it in coronal pulp therapy, we don't want the crown to stained and look grayish so they develop white MTA.

3. Dentin bonding agent has been used in some studies to cap the pulp. Now why Calcium Hydroxide is the most successful direct pulp capping agent and how &why does it work? 1. high PH 2. anti-microbial properties.

the dr now explaining a pic : This is the technique for direct pulp capping, we have an exposed pulp, so the first layer here you place is Calcium Hydroxide or MTA, then you add another layer of GIC to cover all dentin, finally the rest of the tooth filled up with composite for anterior teeth, and stainless steel crown for posterior teeth. I wrote to you in the slides to put composite 4-6 hours later in case you used MTA, why ? -because MTA needs about 4 hours of setting time.

If you use MTA you must have a moist environment, usually we use a wet cotton pellet then we cover it with temporary filling, and then we go back, remove the cotton pullet, and continue our composite filling.

The success rate: 15 % up to 10 years study done by students 82 % up to 21 months study done by clinician

The objectives they are the same for IPC: 1. pulpal vitality 2. no pathological signs 3. continuation of root formation Pulpotomy its the same procedure for primary & permanent teeth except in the level which we cut the pulp, in the primary we cut up to the cervical level we remove all the coronal pulp, in permanent teeth we have two types of pulp therapy : 1. partial pulpotomy (cvek pulpotomy) : we remove only 2 mm of the coronal pulp and we place our medicaments (CH,MTA) 2. cervical pulpotomy : we remove all the coronal pulp like the primary teeth

In both types of permanent pulpotomy we either use Calcium Hydroxide or MTA

The difference between primary & permanent teeth pulpotomy : 1- the level of amputation 2- the material (CH,MTA) indications of pulpotomy: when pulp is exposed: infected & affected coronal pulp amputated and remaining radicular tissue judged to be vital by CLINICAL and Radiographic criteria. so the partial pulpotomoy or CVEK pulpotomy (another name) :the aseptic (using rubber dam),surgical removal pf exposed pulp and dentine surrounding the exposure to a depth of 1.5-2mm.. CVEK indications: 1. traumatic or carious (<2mm) pulp exposure 2. mature or immature (cvek started with immature teeth then he tried with maturwe teeht and compared between them,and there was a very high succes rate in both techniques) 3. normal pulp or rev.pulpitis The AIM of cvek pulpotomy: remove superficial irreversibly inflamed pulp tissue,leaving clean surgical wound..(we only remove the inflamed tissues) then irrigate with NORMAL SALINE until physiological hemostasis..(the bleeding should stop,if the hemorrage doesnt stop you should not perform the procedure) NOTE: now the 2mm is not an exact depth,you measure with you bur and if still there is bleeding you can go alittle bit deeper,if you went deeper and the bleeding still didnt stop then you change your mind and do CERVICAL

PULPOTOMY,you irrigate again and you apply a wet cotton pellet (with NS),apply some pressure and you wait for the bleeding to stop then you apply your medicaments.. the medicaments is the same for both partial and cervical pulpotomy --> CALCIUM HYDROXIDE the pulp wound covered with paste of CH against non bleeding pulp,(essential as blod clot will diminsh chances for hard barrier formationj&long term success).. CVEK MATERIALS: 1.they apply a layer of non-setting CH and then a layer of Hard setting CH then they apply the RMGI or GIC and then the permanent restoration.. 2. the other option is to use MTA the the RMGI or GIC then the permanent restoration.. The dr. then talked about pictures in slides,pls go back and check them. Cvek pulpotomy objectives: Your objectives are the same objectives as any vital pulp therapy technique. success rates: are 96% on traumatically exposed teeth , as u see the first study in 1978,the second one in 1983 and the third one in 1993 in which the success rate is 94% which is quite high ,this is on the carious permanent molars. Factors affecting the success rates : 1.avoid incorporating dentin chips into the pulp wound , meaning when you are removing the caries make sure that all the caries removed before you enter the pulp , with irrigation clean the cavity well before entering the pulp because any dentin chips infected with microorganism enter the pulp will lower the success rate. 2.marginal seal.(very imp)

Cervical pulpotomy : - procedure is as described for formacresol pulpotomy , but we use calcium hydroxide ad medicaments - re-entry following completion of root formation is controversial - and some people recommend RCT later , those are endodontists who said that after cervical pulpotomy you should do RCT. So this is cervical pulpotomy with the same technique : 1. we put the calcium or MTA 2. then we put glass ionomer 3. then all sealed with composite. the possibility of pulp necrosis, infection and pulp canal obliteration prevent negotiation of pulp canal later,and this is the reason why endodontists recommend RCT because these canals may start to close. calcification is infrequent if the pulpotomy procedure is meticulous , this is of course opinions of Cvek and he said that there is no need for RCT if the work done in right manner because there is no calcification will happen. Objectives is the same again!! Apexification: Its a method of inducing calcified barrier in root with open apex which is necrotic. Now , apexification is like RCT except if you have an open apex due to immaturity , which mean there is viable tissue at the apex that has the willing to finish the root formation if it given a chance by removing just the necrotic tissue , this necrotic tissue make the ability of the cells to complete root formation difficult.

So if you remove the necrotic tissue and repeal the inflammation and give these cells a booth by filling with calcium hydroxide, and calcium hydroxide will provide the proper environment for these cells to work by inducing enzymes and providing alkanality and bacteriostatic activity. Also the odontoblasts will start their work so there will be induction from both sides so the root formation will complete and odontoblasts will layer dentin in the root and we will have at the end the root apex formation. Goals of apexification 1.Stimulate and preserve formative activity of granulation tissue cells in apical part of root canal which enhances the formation of calcified callus at apical opening. 2.to form hard tissue barrier to prevent over extension of root filling material into the periapical tisses. Objectives of apexification 1.induce root end closure. 2.no post treatment signs and symptoms. 3.no radiographic evidence pathology. Indications of apexification Indicated for non vital permanent teeth with incompletely formed roots. Techniques of apexification There are two techniques : 1. conventional technique which is multiple visits, 2. modern technique which occur in one to two visits.

The old technique (conventional) still applicable and requires in the first visit preoperative periapical radiographs ,local anesthesia , rubber dam ,determining working length , cleaning and shaping, irrigation with sodium hypochlorite , non setting calcium hydroxide and IRM/GIC. The next visit after 3 months we check if the calcium hydroxide still there or washed away,if its washed away then again,we do cleaning and shaping,irrigation and we put a new layer of non setting calcium hydroxide until the root closes. This technique will take about 6 months to one year or even 1.5 year depending on which stage of root formation we start the procedure,if the formation is completed then it will take 6 months but if it in the middle of formation then it will take 1 year. Its very necessary for calcium hydroxide to go all the way to the end of root because this is where you want apical closure to occur,if it placed in the middle then the there will be barrier in the middle and we wont be able to reach the apical p art of root.this is why after application of calcium hydroxide you should take a radiograph to verify how far the application was. The new technique (modern) requires in the first visit preoperative periapical radiographs ,local anesthesia , rubber dam,access ,determining working length , cleaning and shaping, irrigation with sodium hypochlorite.here we put non setting calcium hydroxide in one visit because the canal is infected and calcium hydroxide will work and just clean it, then we get the patient after one week to put MTA.here we will be finished and get the apical closure and after 4 hours of MTA application we can get the patient back or after one week just to complete the filling. So the second visit can be the last one to put gutta percha .

Apical closure Various types of apical closure have been reported its how to verify if there is apical closure and it is the time to put the gutta percha, this is in case of old technique with calcium hydroxide,it appears that these types of apical closure simply relate to the level to which the filling material was placed within or beyond the apical foramen. The calcified bridge formed following apexification is a porous structure .meaning its quality is not as the original dentin ,but its a little bit lower. If it difficult to determine if and when apical closure has been achieved then there is two ways to know that: 1.by radiographs. 2.by feeling it with a paper point. Types of apical closure 1.apical closure with definite ,minimal ,recession of root canal. (obliterated apex) 2.the obliterated apex develops without changes in root canal space. 3.thin , calcific bridge has developed but without radiographic evidence. 4.calcific bridge but can be determined radiographically . Materials of apexification 1.calcium hydroxide. 2.MTA which produces hard tissue,now why MTA become more widely acceptable nowadays? Because it reduces the treatment time.in other words the one-visit shorten Tx time. potential for fractures of immature teeth with thin roots reduced.because they found that with multiple application of non

setting calcium hydroxide over 1 or 1.5 year will increase the risk of root fracture because the dentin is thin. So the quicker you fill the canal with MTA and gutta percha you will get a stronger root and you will protect the tooth.for this reason MTA is more preferable. Treatment time: Apexification requires 1 year +/- 7 months, and the older children with narrow apex require less than younger children.also the teeth without periapical infection require less than those with infection. The dr skipped the RCT techniques because we know about it..

Done By Musap AL-rawi.. Moori,3o3o,shaggob,ziko,roro <3

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