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Educational Objectives The overall goal of this course is to provide the reader with information on pulpal therapy for primary teeth. Upon completion of this course the reader will be able to: 1. List and describe the clinical and radiographic assessment required to determine appropriate pulp therapy for primary teeth 2. List the indications for vital pulp therapy in primary teeth 3. List and describe the steps involved in pulpotomy of primary teeth and materials that can be used 4. List and describe the steps involved in indirect pulp treatment of primary teeth.
lesion suspected of pulpal involvement (Fig. 1), evaluation of the buccal mucosa around the involved tooth should be made to rule out the presence of a sinus tract or parulis. (Fig. 2) Pulps of nonvital primary teeth often establish drainage through the thin buccal bone, and the presence of a sinus tract is indicative indicative of a necrotic pulp and a direct contraindication to vital pulp therapy. In this situation, extraction or a pulpectomy would be the appropriate treatment. Mobility beyond that expected as a result of normal exfoliation is also a contraindication to vital pulp therapy, as it indicates that the inammatory process in the pulp is involved and has begun to destroy supporting bone. Figure 1. Large carious lesion in primary molar
Abstract Primary tooth pulp therapy can preserve primary teeth until normal exfoliation when clinical conditions permit. Therapeutic options include pulpotomy, indirect pulp treatment and pulpectomy. The appropriate therapeutic options depend on the health of the pulp. In order to determine which treatment option should be pursued, it is necessary to clinically and radiographically assess the tooth. Options for vital primary teeth include pulpotomy and indirect pulp treatment. Provided that careful attention is paid to detail during the clinical procedure and follow-up, as described in this article, both techniques have similar success rates and can save primary teeth.
Figure 2. Sinus tract associated with necrotic pulp in tooth S
Introduction Primary tooth pulp therapy is aimed at preserving the primary teeth until normal exfoliation. Management of the cariously involved primary tooth where the carious lesion approximates the pulp requires a knowledgeable approach to pulp therapy, and a successful outcome depends on accurate diagnosis of the status of the pulp prior to therapy. Preliminary data gathering and interpretation must be focused on determining whether the primary tooth pulp is normal, reversibly inamed, irreversibly inamed or necrotic. If it is determined to be vital or reversibly inamed, the vital pulp therapy techniques of pulpotomy or indirect pulp treatment (IPT) are indicated. If the pulp is determined to be irreversibly inamed or necrotic, either a pulpectomy or extraction would be appropriate. This This course is limited to a discussion of the vital pulp therapy procedures of pulpotomy and indirect pulp treatment (formerly known as indirect pulp capping) for primary teeth. The process of determining that vital pulp therapy can be performed on a primary tooth starts with gathering clinical and radiographic diagnostic data aimed at determining the vitality status of the pulp. Clinical Data The clinical parameters that must be examined are soft tissue changes, pathologic mobility and history of pain. When performing a clinical examination of a tooth with a large carious 2
The use of pulp testing such as cold and hot testing and electric pulp testing to determine pulp vitality is not indicated in young children. The only response one can elicit from a vital pulp is pain, and intentionally causing pain during these tests can scare the child and affect future cooperation. Obtaining a history of presence or absence of pain and type of pain is the major clinical tool for assessing pulp vitality in young children. However, since young children are not reliable historians one must rely on asking about pain history from the caretaker as well as the child. A history of spontaneous pain, www.ineedce.com
such as pain that awakens the child at night, is indicative of an irreversible pulpitis and a dying tooth. Vital pulp therapy is not indicated for such teeth. A history of elicited or provoked pain is more complicated to interpret. Pain on chewing may be the result of compression of the large carious lesion, rather than percussive pain, which is a more ominous sign. To rule out percussive pain, place a tongue blade on an uninvolved cusp of the tooth in question and have the child bite down, watching for signs of discomfort on the child’s face, which would be consistent with percussive pain. If percussive pain is identied, the tooth is contraindicated for vital pulp therapy. Pain elicited from sweets, heat or cold and that is of short duration is not a contraindication to vital pulp therapy but should be recorded in the data collection sheet. Radiographic Data A bitewing and periapical radiograph are necessary to assess the pulpal status of a primary tooth with a large carious lesion. (Fig. 3) The bitewing is the best view to assess the proximity of the carious lesion to the pulp. It is also the best lm to view the furcation of the primary tooth, which is where the rst signs of necrotic pulp in primary teeth appear. Accessory canals in the oor of the primary tooth pulp chamber allow the toxins from the necrotic pulp in the chamber to travel into the furcation and affect that bone rst. Loss of lamina dura and decreased radiopacity of the bone in the furcation are the rst signs of dead or dying pulps, and teeth demonstrating these radiographic changes would not be candidates for vital pulp therapy. The superimposition of the furcation of the maxillary molars on the palatal root makes accurate reading for radiolucency in the earliest stages difcult in maxillary molars. Figure 3. Bitewing and periapical radiograph of first primary molar with carious lesion approximating the pulp
The following is a summary of the indications for vital pulp therapy in primary teeth: 1. A large carious lesion approximating the pulp where pulp exposure is expected with complete caries removal. www.ineedce.com
2. The absence of soft tissue pathology such as sinus tract, tract, pathological mobility and spontaneous pain. 3. The absence of radiographic changes of furcation radiolucency, internal or external root resorption or periapical pathology. 4. A restorable tooth. 5. At least one-third of the root remaining. Once the decision has been made that the pulp is vital or only demonstrates signs of reversible pulpitis, the dentist must decide which pulp therapy technique to use, pulpotomy or indirect pulp treatment (IPT). The indications are exactly the same for both procedures, and the only disadvantage with IPT is the loss of the last diagnostic tool that is provided by the pulpotomy technique, the ability to actually view the pulp during pulp removal to conrm the accuracy of the diagnostic workup. Recent best evidence indicates that IPT has similar success rates to pulpotomy in primary teeth and is now considered a viable alternative. 1-6 Both procedures will be discussed in the following sections. Prior to any invasive procedure with the potential to cause pain, adequate local anesthesia must be administered. A well-tting rubber dam that controls for salivary contamination is required for both pulpotomy and IPT.
Pulpotomy Technique The pulpotomy technique involves removal of the coronal pulp, leaving healthy pulp tissue in the canals. In order to minimize bacterial contamination, supercial caries must be removed before exposing the pulp and beginning the access opening. Following caries removal and exposure of the pulp, begin the access opening to remove the roof of the pulp chamber. A proper access opening to the pulp chamber is the most important step in ensuring complete removal of the coronal pulp. Tissue tags inadvertently left during pulp removal are the most common cause of inability to control hemorrhage. (Fig. 4) A wide, adequate access opening facilitates visualization of the chamber and removal of all tissues down to the orices of the canals. The cusp tips are guides to the number and location of all pulp horns, and should be used to identify and expose all pulp horns to guide the outline of the opening and ensure that access to the pulp chamber is at the extent of the peripheral walls of the chamber. When the roof of the pulp chamber is removed, there should be no ledges and the walls of the access opening should be conuent with the walls of the chamber. (Fig. 5) The pulp should bleed when the roof is removed and the pulp chamber is accessed; bleeding is an indicator of a vital pulp. If the chamber is empty and dry or lled with purulent material, the pulpotomy procedure cannot be continued and the tooth must be treated with either a pulpectomy or an extraction. The access opening and removal of the roof of the chamber are best made with a high-speed handpiece and water coolant, but actual removal of the pulp tissue should be done with a spoon excavator or a large round bur in a slow-speed handpiece. (Fig. 6) Use of a high-speed hand3
piece in the chamber has the potential to perforate the oor of the chamber due to the small size and shallow depth of the chamber and the wiggly nature of children. Once all tissue is removed, use small cotton pellets wet with water under gentle pressure to control hemorrhage and to clean the chamber. (Fig. 7) If hemorrhage control is not obtained within 5 minutes, the pulp should not be considered further for a pulpotomy. Inability to control hemorrhage is an indication that the inammatory process has moved into the root canals and is a contraindication to vital pulp therapy. Once hemorrhage control has been obtained and the chamber is clean, the pulpotomy medicament may be applied. Formocresol is the most frequently used primary tooth pulpotomy medicament,5 but there are two other very well researched alternative medicaments for the pulp stumps, ferric sulfate 8-15 and mineral trioxide aggregate (MTA). 16-21 The decision about which medicament to use is up to the operator. Formocresol and ferric sulfate have similar success rates 15 and MTA has the highest reported success rate of the three. 21 However, MTA is very expensive and therefore used less frequently frequently.. These medicaments will be considered separately due to the differences in application technique.
Figure 6. Coronal pulp tissue is removed to the level level of the opening into the canals.
Figure 7 . Hemorrhage control control using a water-dampened water-dampened cotton pellet.
Figure 4. Inadequate access opening results in leaving pulp pulp tissue and tissue tags in pulp chamber.
Figure 8. Actual pulpotomy procedure
Figure 5. Access opening with no ledges and walls walls confluent with walls of pulp c hamber.
Formocresol A 1:5 dilution of Buckley’s formocresol (19% formaldehyde) is recommended for the pulp medicament. 1,22-23 This is the concentration that has been used for the majority of recent investigations of formocresol pulpotomy, and the dilution is best performed by a pharmacist. It should be noted that Buckley’s formocresol is not available for purchase in its diluted form. The formula for diluting formocresol is to mix 3 parts of glycerin with 1 part of distilled water to form a diluent, and add 4 parts of diluent to 1 part of Buckley’s formula formocresol.22 Another concentration of formocresol is available 4
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that has 45.8% formaldehyde; caution is recommended when purchasing formocresol to be sure that the correct concentration, Buckley’s formula, is being purchased. 24 A great deal of attention has been paid recently to the undesirable features of formocresol, and current recommendations are to use the least amount possible, a 1:5 dilution of Buckley’s formocresol. formocresol. 25 The steps involved using this technique are as follows: Soak a small cotton pellet (two pellets for second molars) in formocresol, and blot it/them very dry with a 2x2 inch gauze. Take care to use only a dampened, not soaking wet, pellet. The pellets are placed snugly over the pulp stumps and packed tightly into place with a dry cotton pellet to ensure that no excess formocresol oozes out of the tooth onto the gingiva. (Fig. 9) The pellets are left in place for ve minutes and then gently teased away from the pulp stumps with an explorer, being careful not to initiate bleeding from the pulp stumps. If bleeding recurs, initiate hemorrhage control again and reapply the formocresol to the pulp stumps. The formocresol pellet MUST be removed and not left in the pulp chamber. A thick mix of zinc oxide and eugenol (ZOE), either plain or reinforced, is placed in the chamber and carefully packed tightly against the pulp stumps with a dampened cotton pellet. It is important to be sure that the paste is well condensed onto the oor of the pulp chamber and against the orices of the canals. The base formed by the zinc oxide eugenol (ZOE) covering the canals’ openings should be at least 3–4 millimeters thick and form a good seal for the orices of the pulp canals. The tooth should be restored at the same appointment.
stumps. It is important to be sure that the paste is well condensed onto the oor of the pulp chamber and against the orices of the canals. The base formed by the ZOE covering the canals’ openings should be at least 3–4 millimeters thick and form a good seal for the orices of the pulp canals. The tooth should be restored at the same appointment. MTA MTA is available commercially as ProRoot MTA (Dentsply International, York, Pennsylvania) as a powder and liquid formulation (Fig. 10 A–B) that must be mixed to form a medium-thick paste. The powder is placed on the mixing pad and mixed with the sterile water from the manufacturer. For one pulpotomy, only about one-quarter of the powder is needed, and the packet can be folded over and paper-clipped closed. Place the packet in a sealable plastic bag and close tightly to create a moisture-free environment. The water supplied by the manufacturer comes in a premeasured plastic tube that cannot be saved after it has been opened. For the other mixes from the same packet, you can use either sterile saline (purchased from a pharmacy) or local anesthetic solution. The remaining powder should be used within a few weeks or discarded and a new packet opened. Figure 10A. MTA powder powder removed from packet
Figure 9. Application of formocresol-dampened cotton pellets to the pulp stumps.
Figure 10B. MTA mixed with sterile saline or water
Ferric Sulfate Ferric sulfate, a hemostatic agent, is available commercially as Astringedent (Ultradent Products, Inc., Salt Lake City, Utah) and comes with an applicator tip. Following hemorrhage control, the infuser or brush tip is gently applied to the pulp stumps for 10–15 seconds. 8 The pulp chamber should then be gently rinsed with water and dried with cotton pellets.8 A thick mix of ZOE, either plain or reinforced, is placed in the chamber and carefully packed tightly against the pulp www.ineedce.com
The medium-thick mix of MTA is carried to the chamber on a spatula and condensed gently over the pulp stumps and the oor of the pulp chamber, being sure to have about a 2 millimeter thickness of paste over the stumps. (Fig. 11 A–D) A resin-modied glass ionomer (RMGI) is used as the base over the MTA, and care is taken not to disturb the MTA during placement and curing of the RMGI. The MTA takes 3–4 hours to completely set, 7 and the resin-modied glass ionomer provides the protection needed during this setting time. The tooth should be restored at the same appointment. 5
Figure 11A. Hemorrhage control.
The restoration of choice for primary teeth that have received a pulpotomy is a stainless steel crown (SSC). 7,22-23 The pulpotomized tooth has been weakened by the caries and the amount of tooth structure removed during pulpotomy procedures. The full-coverage aspect of the SSC protects the weakened tooth structure and ensures the biological seal required for successful pulpotomy over time. The base used over the orices for the root canals should be separate from the cement used to cement the SSC. If the SSC should come off, the separate base will ensure that the pulpotomy remains sealed until the child can return to the dental ofce for the SSC to be replaced.
Figure 11B. MTA mixed to thick paste on condenser.
Indirect Pulp Therapy
Figure 11C. MTA placement over pulp stumps.
Figure 11D. RMGI base placed.
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Another vital pulp therapy technique for the primary tooth with a large carious lesion closely approximating the pulp that would result in an exposure if all the caries were removed is indirect pulp treatment (IPT). 1-6,7,22-23 The technique of IPT requires that some caries be left in the tooth to avoid an exposure. The IPT technique recommended for primary teeth is the one-appointment technique, and the tooth is not reentered to remove the residual caries. The The rst step is to remove the supercial and peripheral caries, and this can be performed with a highspeed bur with water coolant. All peripheral walls must be cleaned to sound dentin, leaving the caries over the pulp. The The caries over the pulp is best removed with a large round bur (#6) on slow speed. Spoon excavators should be avoided, as they can remove large chunks of dentin and the pulp could be inadvertently exposed. The The slow-speed round bur gives the operator more control over how much affected dentin to remove and when to stop. Using a slowspeed handpiece with a large round bur, carefully remove the softened, infected dentin over the pulp. A decision should be made at the beginning of the procedure to stop caries removal when the slow-speed bur is creating powder and the dentin appears leathery, leathery, though still softened, regardless of the color of the remaining dentin. This is “affected dentin,” and because affected dentin is not infected with large numbers of microorganisms and has the ability to remineralize if it has a biological seal, it is acceptable to leave 1–2 millimeters over the pulp. 26 (Fig. 12) Do not be overzealous in caries removal and risk pulp exposure. The remaining affected dentin must be covered with a base that ends on sound dentin and provides a biological seal over the affected dentin left behind. So long as the seal is maintained, any bacteria in the affected dentin will die or become inactive, and the dentin will remineralize and become harder.26 The two materials recommended for basing IPTs are reinforced ZOE products such as Caulk IRM Intermediate Restorative Material (Dentsply International) or RMGI. The tooth is restored with an SSC as described previously. www.ineedce.com
Figure 12. Removal of infected dentin, leaving leaving discolored, affected dentin to avoid a pulp exposure.
Figure 13. Follow-up radiograph of pulpotomized tooth (K) demonstrating calcific metamorphosis.
Figure 14. Follow-up radiograph of pulpotomized tooth (T) demonstrating contained internal resorption.
Courtesy of J. Coll, York, PA.
Follow-Up Follow-up of teeth receiving vital pulp therapy is very important. Every six months, periapical radiographs of the treated teeth should be taken and read. These radiographs should be compared with the preoperative radiographs to observe for changes over time. No change between the preoperative and follow-up radiograph is the gold standard for success. However, many primary teeth receiving vital pulp therapy, especially pulpotomy, will show changes over time. A common nding is uniform narrowing of the canals which is called calcic metamorphosis and indicates an attempt on the part of the pulp to heal. (Fig. 13) Over time the entire pulp canal may be entirely obliterated. These teeth rarely progress to failure, and this nding is considered a success. Another change in the root canals seen less frequently than calcic metamorphosis is internal resorption. (Fig. (Fig. 14) If it is minor and conned to the canal, it can be watched, as recent publications in the literature have reported that many teeth demonstrating this nding do not progress to failure over time. 8,27 However, these teeth are vital and are demonstrating a potentially selfdestructive change. If it continues, it will perforate the root and involve supporting bone. At this point, the tooth must be extracted as the pulpotomy has failed. (Fig. 15) Any osseous radiolucencies or evidence of external root resorption not associated with normal exfoliation are evidence of pulpal death and indicate that the treatment has failed. (Fig. 16) Teeth demonstrating these changes must be extracted and space management considered, depending on the child’s age and eruption patterns. www.ineedce.com
Figure 15. Follow-up radiograph of pulpotomized tooth (L) demonstrating perforating internal resorption.
Figure 16. Follow-up radiograph of pulpotomized tooth (K) demonstrating furcation radiolucency and external resorption.
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In summary, many primary teeth with large carious lesions approximating the pulp can be saved until normal exfoliation through careful diagnostic assessment to determine the appropriateness of vital pulp therapy and attention to the details of technique and follow-up.
References 1.
Far aroo ooq q NS NS, , Col Coll l JA JA, , Ku Kuwa waba bara ra A, Sh Shel elto ton n P. Su Succ ccess ess ra rate tes s of for formoc mocres resol ol pul pulpot potomy omy and ind indire irect ct pul pulp p the therap rapy y in the treatment of deep dentinal caries in primary teeth. Pediatr Dent.2000;22:278-286. 2. Fal alst ster er CA, Ar Arau aujo jo FB FB, , St Stra raff ffon on LH LH, , No Nor r JE JE. . In Indi dire rect ct pu pulp lp treatment: in vivo outcomes of an adhesive resin system vs calciumhydoxideforprotectionofthedentin-pulpcomplex. PediatrDent.2002;24(3):241-248. 3. Moh Mohamme ammedA,Al-Zay dA,Al-ZayerMA,Str erMA,Straffo affonLH,Fe nLH,Feiga igalRJ,W lRJ,Welc elch h KB. KB . In Indi dire rect ct pu pulp lp tr trea eatm tmen ent t of pr prim imar ary y pos poste teri rior or te teet eth: h: a retrospectivestudy.PediatrDent.2003;25:29-36. 4. VijR,Coll VijR,CollJA,Shelto JA,SheltonP nP,Fa ,FarooqNS. rooqNS.Cariescont Cariescontrolandoth rolandother er variablesassociatedwithsuccessofprimarymolarvitalpulp therapy.PediatrDent.2004;26:214-220. therapy .PediatrDent.2004;26:214-220. 5. Fuk Fuks s AB. AB.Vital Vital pul pulp p the therap rapy y wit with h new mat materi erials als for pri primar mary y teeth:Newdirectionsand teeth:New directionsandtreatmentperspectiv treatmentperspectives.Pediatr es.PediatrDent. Dent. 2008;30:211-219. 6. CollJA. CollJA.Indirectpulp Indirectpulpcappingand cappingandprimaryteeth: primaryteeth:Isthe Istheprimary primary toothpulpotomyoutofdate?PediatrDent.2008;30:230-246. 7. Ca Camp mp JH, Fu Fukks AB AB. . Ped edia iatr tric ic en endo dodo don nti tics cs: : En Endo dodo don nti tic c treatmentfortheprimary treatmentfor theprimary andyoungpermanent dentition.In: CohenS,HargreavesKM,eds.PathwaysofthePulp.9thed.St. Louis,CVMosbyCo.;19--:822-82. 8. Sm Smit ith h NL NL, , Se Seal ale e NS NS, , Nu Nunn nn ME ME. . Fer erri ric c su sulf lfat ate e pu pulp lpot otom omy y in pr prim imar ary y mo mola lars rs; ; a re retr tros ospe pect ctiv ive e st stud udyy. Pe Pedi diat atr r De Dent nt. . 2000;22:192-199. 9. Fei FeiAL,UdinRD AL,UdinRD,Johnson ,JohnsonR.Aclinical R.Aclinicalstudyofferric studyofferricsulfateas sulfateas apulpotomyagentinprimaryteeth.PediatrDent.1991;13:327332. 10. Fuk Fuks s AB, Hol HolanG, anG, Dav DavisJM, isJM, Eid Eidelm elmanE. anE. Ferr erricsulfa icsulfatevs tevs diluteformocresolinpulpotomizedprimarymolars;long-term follow-up.PediatrDent.1997;19:327-330. 11. Pa Papag pagia iann nnou ouli lis s L. Cl Clin inic ical al st stud udie ies s on fe ferr rric ic su sulp lpha hate te as a pulpot pul potomy omy medi medicame cament nt in pri primar mary y mol molars ars. . Eur J Paea Paeadia diatr tr Dent.2002;3:126-132. 12. Ibric IbricevicH, evicH, Al-Jam Al-Jame e Q.Ferric sulfat sulfate e as pulpot pulpotomyagentin omyagentin primaryteeth;twenty-monthclinicalfollow-up.JClinPediatr Dent.2000;24:269-272. 13. HuthKC,PaschosE, Hajek Hajek-Al-Kha -Al-KhatarN, tarN, etal. Effect Effectiven iveness ess offourpulpotomytechnique offourpulpotomy techniques:Randomize s:Randomizedcontrolle dcontrolledtrial.J dtrial.J DentRes.2005;84:1144-1148. 14. Mar Markov kovic ic D, Zib Ziboji ojinov novicV icV, , Buc Buceti etic c M. Eva Evalua luatio tion n of thr three ee pulpotomymedicamentsinprimaryteeth.Eur pulpotomymedicamentsin primaryteeth.EurJPaediatrDent. JPaediatrDent. 2005;6:133-138. 15. 15 . Pen eng g L, Ye L, Gu Guo o X, Tan H, Zh Zhou ou X, Wan angg C, Li R. Evaluationofformocresolversusferricsulphateprimarymolar pulpotomy:asystematicreviewandmeta-analysis.IntEndod J.2007;10:751-757. 16. Agamy AgamyHA,BakryNS,Mouni HA,BakryNS,MounirMM,Aver rMM,AveryDR.Compariso yDR.Comparison n of mi mine nerral tri rio oxi xide de ag aggr greg egat ate e an and d fo forrmo mocr cres esol ol as pu pullpcappingagentsinpulpotomizedprimaryteeth.PediatrDent. 2004;26:302-309. 17. Jab Jabbar barifa ifar r SE, Khad Khadeni eni DD DD, , Gha Ghasen seni i DD DD. . Suc Success cesss s rat rates es of formocresolpulpotomyvsmineraltrioxideag formocresolpulpotomyvsmin eraltrioxideaggregateinhuman gregateinhuman primarymolartooth.JResMedSci.2004;6:55-58. 18. Fa FarsiN, rsiN,Alamoudi AlamoudiN,Balt N,BaltoK,Musha oK,MushaytA.Succ ytA.Successofmine essofmineral ral trioxide aggregate in pulpotomized primary molars. J Clin PediatrDent.2005;29:307-311. 19. 19 . Ho Hola lan n G, Ei Eidel delma man n E, Fu Fuks ks AB AB. . Lo Long ng-t -ter erm m ev eval alua uati tion on of
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pulpotomyinprimarymolarsusingmineraltrioxideaggregate andformocresol.PediatrDent.2005;27:129-136. 20. NaikS,HedgeAM.Mineraltrioxideaggregateasapulpotomy agentinprimarymolar agent inprimarymolars:aninvivostudy s:aninvivostudy.JIndianSocPedod .JIndianSocPedod PrevDent.2005;23:13-16. 21. NgFK,Me NgFK,MesserLB sserLB.Miner .Mineraltri altrioxid oxideaggre eaggregateasa gateasapulpoto pulpotomy my medi me dica came ment nt: : An ev evid iden ence ce-b -bas ased ed as asse sess ssme ment nt. . Eu Eur r Ar Arch ch Paediat Paed iatr r Den Dent. t. 2008 2008;9: ;9:58-7 58-73. 3. In: McD McDona onald ld RE, Av Avery ery DR, eds.DentistryfortheChildandAdolesc eds.Dentis tryfortheChildandAdolescent.6thed.StLouis: ent.6thed.StLouis: Mosby-YearBook,Inc.;1994:428-454. 23. FuksAB.Pulp FuksAB.Pulptherapy therapyfortheprimary fortheprimarydentiti dentition.In:Pink on.In:Pinkham ham JR,CasamassimoPS,FieldsHW JR,CasamassimoPS,F ieldsHW,McTigue ,McTigueDJ,Nowak DJ,NowakAJ,eds. AJ,eds. PediatricDentistry:InfancyThroughAdolescence.4thed.St. Louis:ElsevierSaundersCo.;2005:375-393. 24. 24 . Ki Kin ng SR SR, , Mc McWh Whor orte ter r AG, Se Seal ale e NS NS. . Co Conc ncen entr trat atio ion n of form fo rmoc ocre reso sol l us used ed by pe pedi diat atri ric c de dent ntis ists ts in pr prim imar ary y to toot oth h pulpotomy.PediatrDent.2002;24:157-159. 25. 25 . Mi Miln lnes es AR AR. . Is fo form rmoc ocre reso sol l ob obso sole lete te: : A fr fres esh h lo look ok at th the e evidence.PediatrDent.2008;30:237-246. 26. Bjornda BjorndalL, lL,LarsenT LarsenT,,ThylsrupA.A ThylsrupA.Aclinica clinicalandmicrobiologic landmicrobiological al studyofdeepcariouslesionsduringstepwiseexcavationusing longtreatmentintervals.CariesRes.1997;31:411-417. 27. Zurn D, Seale NS. Light-c -cu ured calcium hydr dro oxi xid de vs formocresolinhumanprimarymolarpulpotomy:arandomized controlledtrial.PediatrDent.2008;30:34-41.
Author Profile N. SUE SEALE, DDS, MSD
Dr. N. Sue Seale is Regents Professor, Department of Pediatric Dentistry, Baylor College of Dentistry, Texas A&M Health Science Center in Dallas, Texas. She received her DDS in 1970, her certicate in pediatric dentistry in 1972 and her MSD in 1979 from Baylor and has been a full-time faculty member since 1974. She was president of the Texas Academy of Pediatric Dentistry 1996-1997 and received the Distinguished Alumni Award from the Baylor College of Dentistry Alumni Association in 1997; she served on the Board of Trustees of the American Academy of Pediatric Dentistry from 1999-2002. In 2001, the American Academy of Pediatric Dentistry named her Pediatric Dentist of the Year and presented her with the Merle C. Hunter Hu nter Leadership Award in 2003. She is a diplomate of the American Board of Pediatric Dentistry and received Fellowship in the American College of Dentists in 1984 and in the International College of Dentists in 2001. She was Chairman of the Department of Pediatric Dentistry at Baylor from 1986 until 2009.
Disclaimer The author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.
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Questions 1. Primary tooth pulp therapy is aimed at preserving the primary teeth until normal exfoliation. a. True b. False
2. Vital pulp therapy techniques for primary teeth are indicated for _________. a. b. c. d.
primary teeth that are reversibly inamed primary teeth that are irreversibly inamed nonvital teeth none of the above
3. The process of determining that vital pulp therapy can be performed on a primary tooth starts with gathering _________. a. b. c. d.
clinical diagnostic data but not from a pulp test clinical diagnostic data including from a pulp test radiographic diagnostic data a and and c
4. When performing a clinical examination of a tooth with a large carious lesion suspected of pulpal involvement, evaluation of the buccal mucosa around the involved tooth should be made to _________. a. b. c. d.
check for buccal gingivitis check for mucosal mucosal sloughing rule out the presence of a sinus tract or parulis none of the above
5. _________ is a contraindication to vital pulp therapy. a. The presence of a sinus tract b. Mobility beyond that expected as a result of normal exfoliation c. A large carious lesion d. a and and b
6. Obtaining a history of presence or absence of pain and type of pain is the major clinical tool for assessing pulp vitality in young children. a. True b. False
7. A history of spontaneous pain, such as pain that awakens the child at night, is indicative of an irreversible pulpitis and a dying tooth. a. True b. False
8. The rst signs of necrotic pulp in primary molar teeth _________.
11. The bitewing is the best view to assess the proximity of the carious lesion to the pulp. a. True b. False
12. Vital pulp therapy techniques for primary teeth are _________. a. b. c. d.
pulpectomy and indirect pulp treatment pulpotomy and indirect pulp treatment root resection none of the above
13. A well-tting rubber dam that controls for salivary contamination is required for vital pulp therapy therapy.. a. True b. False
14. _________ is the most important step in ensuring complete removal of the coronal pulp. a. A proper access opening to the pulp chamber b. The provision of local anesthesia c. The use of a sharp excavator to remove the pulpal tissue d. all of the above
15. During a pulpotomy procedure, supercial caries must be removed before exposing the pulp and beginning the access opening in order to minimize bacterial contamination. a. True b. False
16. The inability to control hemorrhage is most commonly due to _________. a. medication use b. tissue tags inadvertently left during pulp removal c. the application of inadequate pressure to the pulpal stumps d. none of the above
17. If the pulp chamber is empty and dry or lled with purulent material, or if hemorrhage control is not obtained within 5 minutes, a pulpotomy procedure cannot be continued. a. True b. False
18. Small cotton pellets wet with water under gentle pressure should be used _________. ______ ___.
appear in the furcation of the tooth are in variable locations are when the tooth becomes mobile none of the above
a. once all pulp tissue is removed from the pulp chamber b. to control hemorrhage c. to clean the pulp chamber d. all of the above
9. Indications for vital pulp therapy in primary teeth include _________ .
19. _________ can be used as a medicament for a pulpotomy pulpotomy..
a. b. c. d.
a. a large carious lesion approximating the pulp where pulp exposure is expected with complete caries removal b. a restorable tooth and with at least one-third of the root remaining c. the absence of soft tissue pathology such as sinus tract, pathological mobility and spontaneous pain d. all of the above
10. It is not necessary that there is an absence of radiographic changes of furcation radiolucency, internal or external root resorption or periapical pathology for vital pulp therapy to be indicated in primary teeth. a. True b. False
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a. b. c. d.
Formocresol Ferric sulfates Mineral trioxide aggregate (MTA) (MTA) any of the above
20. A 1:3 dilution of Buckley’s formocresol is recommended for the pulp medicament. a. True b. False
21. A small cotton pellet dampened, not soaking, with formocresol is packed against the pulp stumps for ve minutes before being gently removed during pulpotomy with formocresol as the medicament. a. True b. False
22. Formocresol-dampened cotton pellets must be removed from the tooth after use during the pulpotomy procedure. a. True b. False
23. Irrespective of the pulpotomy medicament and technique, the tooth should be restored at the same appointment as the pulpotomy. a. True b. False
24. Following use of mineral trioxide aggregate as a pulpotomy medicament, the tooth should receive _________. a. b. c. d.
composite sealant resin-modied glass ionomer a and and c
25. A thick mix of zinc oxide and eugenol, either plain or reinforced, is placed in the pulp chamber and carefully packed tightly against the pulp stumps with a dampened cotton pellet to cover the canals following pulpotomy with either ferric sulfate or Buckley’s formocresol. a. True b. False
26. The restoration of choice for primary teeth that have received a pulpotomy is a stainless steel crown. a. True b. False
27. The indirect pulp treatment technique recommended for primary teeth is the one-appointment technique, and the tooth is not reentered to remove the residual caries. a. True b. False
28. During the removal of soft, carious dentin for an indirect pulp cap technique, the caries over the pulp is best removed with _________. a. b. c. d.
an excavator a round diamond in a high-speed handpiece a large round bur (#6) on slow speed all of the above
29. A change that may be observed radiographically graphicall y in a primary teeth that has received vital pulp therapy is _________. a. b. c. d.
calcic metamorphosis internal resorption resorption of zinc oxide eugenol a and and b
30. A decision should be made at the beginning of the indirect pulp treatment procedure to stop caries removal when the slow-speed bur is creating powder and the dentin appears leathery, though still softened, regardless of the color of the remaining dentin. a. True b. False 9
ANSWER SHEET
Vital Pulp Therapy Therapy for the Primary Dentition Name:
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Requirementsforsucces Requirem entsforsuccessfulcomp sfulcompletion letionofthecourseandtoobtainden ofthecourseandtoobtaindentalcontin talcontinuingeduc uingeducation ationcredits:1)Readtheent credits:1)Readtheentirecourse irecourse.2)Complet .2)Completeall eall informationabove.3)Comp informationabov e.3)Completeanswersh leteanswersheetsineitherpen eetsineitherpenorpencil.4)M orpencil.4)Markonlyonean arkonlyoneanswerforeach swerforeachquestion.5)Ascoreof70% question.5)Ascoreof70%onthistestw onthistestwillearn illearn For Questions Call 216.398.7822 you4CEcredits.6)CompletetheCourseEvaluationbelow.7)MakecheckpayabletoPennWellCorp.For Ifnottakingonline,mailcompletedan Ifnottakingonline,ma ilcompletedanswershee swersheetto tto
Educational Objectives
Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp.
1. Listanddescribetheclinicalandradiographicassessmentrequiredtodetermineappropriatepulptherapy
P.O.Box116,Chesterland,OH44026 orfaxto:(440)845-3447
forrpr fo prim imar ary yte teet eth. h. 2. Listthe Listtheindica indicationsf tionsforvitalpulp orvitalpulptherapyinpr therapyinprimaryt imaryteeth. eeth. 3. Listanddescribethestepsinvolvedinpulpotomyofprimaryteethandm aterialsthatcanbeused.
For immediate rsuls, go o ww w.nc. w.nc.co co n clck on h buon “tk tss Onln.” answr shs cn b fx wh cr cr pyn o (440) 845-3447, (216) 398-7922, or (216) 255-6619.
4. Listanddescribethestepsinvolvedinindirectpulptreatmentofprimaryteeth.
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Course Evaluation Pleaseevaluatethiscoursebyrespondingtothefollowingstatements,usingascaleofExcellent=5toPoor=0. 1.Were W ereth the ein indi divi vidu dual alccou ourse rseob obje jecti ctivesm v esmet et??
Objective#1: Yes No
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10.Ifanyofthecontinuingeducationquestionswereunclearorambiguous,pleaselistthem. Ifanyofthecontinuingeducationquestionswereunclearorambiguous,pleaselistthem. ___________________________________________________________________ 11.Wasthereanysubjectmatteryoufoundconfusing?Pleasedescribe. Wasthereanysubjectmatteryoufoundconfusing?Pleasedescribe. ___________________________________________________________________ ___________________________________________________________________ 12.Whatadditionalcontinuingdentaleducationtopicswouldyouliketosee? Whatadditionalcontinuingdentaleducationtopicswouldyouliketosee? ___________________________________________________________________ ___________________________________________________________________
AGD Code 430, 074, 734
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER The author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or
[email protected].
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INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive conrmation of passing by receipt of a verication form. Verication Verication forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The opinions of ecacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reect those of PennWell. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.
COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verication form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell PennWell is a California Provider. Provider. The California Provider number is 4527. The cost for courses ranges from $49.00 to $110.00. Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certied to meet DANB’s annual continuing education requirements. To nd out if this course or any other PennWell course has been approved by DANB, please contact DANB’s Recertication Department at 1-800-FOR-DANB, ext. 445.
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