1. Pulp therapy

2. Diagnostic aids for selection of the tooth for vital pulp therapy:
History of pain:
Although history of presence or absence of pain may not be as reliable in dental diagnosis in children as in permanent teeth because of:
Children may be unable of communication about pain
In case of pulpal necrosis, there is pulpal degeneration but no pain but still it should be considered.

3. Indicates: Dentist should distinguish between 2 types of pain:
Provoked pain
Induced by stimulus (cold, hot, chemical)
Disappear after removal of stimulus
Indicates:
Pulp is vital but having minimum reversible damage
Protected by thin dentine layer 

4. Spontaneous (unprovoked) pain
Constant, throbbing pain that may keep patient awake at night
Indicates:
Advanced pulp damage (irreversible) with no chance to maintain vitality. 
Clinical examination:
Soft tissue examination:-
Examine intra and extra oral tissues for:
Swelling or abscess.
Fistulous tract.
Lymphadenopathy (tender & enlarged).
Abscess or fistula → endo. Treatment or extraction.

5. Hard tissue examination:-
Visual examination
Discoloration, loss of translucency → pulp degeneration
Destruction of enamel and dentine due to caries or trauma
Broken, missing restoration
Size of pulpal exposure and amount of pulpal bleeding → which is a very important valuable observation in decision of vital pulp therapy where if :
-vital pulp therapy → small, pin point, surrounded by sound dentine
-non-vital pulp therapy → large associated with watery exudates or pus. 

6. Palpitation Mobility Causes of mobility: Bony contour.
Compare with contra-lateral .
Mobility
Causes of mobility:
Normal exfoliation.
Trauma → root fracture.
Advanced pulp inflammation may involve supplemental structure cause its damage.
Mobility may be associated with pain or pain is absent which indicates → chronic Degeneration.

7.  Sensitivity to percussion
Start with gentle tapping by the tip of finger, then proceed using back of mirror
Indicates:
Acute pulpal inflammation in 2 direction
-axial ''periapical''
-lateral ''periodontal''
In some conditions tooth mobility & sensitivity to percussion or pressure may be a sign of high restoration, advanced periodontal disease. However

8. Vitality test: Pulp testing are:
Although vitality test is not reliable tool in children as false results may be due to :
Child apprehension.
Transmition of stimuli to gingival, periodontal ligament and bone but still should be kept in consideration
Pulp testing are:
1-Thermal pulp testing:
Hot → hot gutta purcha, hot instrument
Cold → ethyl chloride, ice sticks (H2O freezed in empty L.A carpule)

9. Technique: apply first on normal tooth to allow child experience normal response which is pain on application that disappears on removal of stimulus
If pain persists longer → pulpities
No pain → non-vital pulp.
Limitations :
No reliable evidence about degree of pulp disease (inflammation).
Affected by size of pulp champer (difficult with small size pulp champer).

10. 2-Electric pulp testing:
Using electric pulp tester (electric vitalometer)
First record reading of normal tooth, then record reading of affected one and observe:
-Respond at higher level : pulp degeneration
-Respond at lower level: hyperemia or pulpities
-No response: necrosis (non vital)
Limitation:
Electric pulp irritation
False +ve in case of:
- Liquefaction necrosis
- Pulpless tooth in contact with vital one by crown or ortho. Appliance
- Single vital canal
-Loss of child confidence if apprehensive

11. Radio evaluation covers:
Radiographic examination
Periapical & bitewing x-rays
Radio interpretation is more different in children > adults due to:
1- Young permanent teeth with incomplete root formation → periapical RL.
2- Physiologic root –ve → pathological condition
3- Superimposition of permanent on primary
Radio evaluation covers:
1- Anatomical aspects:
-shape, size, length and number of roots (PA)
-Divergence of roots (PA)
-Location of pulp horns (BW)

12. 2- Pathological aspects:
proximity of caries to pulp (BW)
Internal –ve (PA, BW)
periapical (permanent) or furcation (primary) involvement (PA, BW)
Thickness of P.M space (PA)
reparative dentine (BW)
3- Developmental aspects:
stage of development: root formation/ apical closure/ physiologic –ve stage of succadaneous tooth eruption (PA)
degree of pulp maturity: size of chamber (BW) / width of root canal (PA)
Others: dens in dent (BW, PA) - absence of successor (PA) - taurodontism (PA, BW)

13. Physical condition of child:
Physical condition of child plays an important role in decision of pulp treatment.
Seriously ill child suffering from:
Heart disease
Nephritis
Leukemia
Solid tumors (malignant)
Cyclic neutropenia
-Should not be subjected to possibility of acute infection resulting from pulp therapy
-In addition, some systemic disease may affect the regenerative power of pulp following pulp capping
-So in such cases proper premedication and extraction

14. Treatment of deep carious lesions
Vital pulp therapy for primary teeth:
Indirect pulp capping: 
-Definition: it is the process in which only gross caries is removed & cavity is properly sealed (extremely important) for certain (6-8 week) time using bactericidal agent.
-Aim: preserve pulp vitality, arrest caries process (rationale).  -

15. Advantage: (IPC). 1- Preserve vitality
2-Saves tooth strength & tooth integrity
3-Arrests activity of caries process by sealing off & destroying reaming microorganism
4-Promotes reparative dentin formation

16. 2-Deep carious lesion approximating pulp not involving it
Indications: (IPC).
1- Young primary & permanent teeth → having high reparative & regenerative power.
2-Deep carious lesion approximating pulp not involving it
3-Absence of any sign of spontaneous pain
4-Vital pulp
5-Normal radiograph findings
6-Good physical condition of patient
7-Restorable

17. Contraindication:( IPC).
1-aged pulp in a mature primary teeth
Decrease regenerative potential of pulp
Resorption > 2/3 root
2-non-vital pulp
3-history of spontaneous pain
4-tooth decayed beyond repair or near exfoliation
5-existing pathologic pulp exposure

18. Contraindication (IPC) Follow.
6-radiographic evidences of pulp pathos is :
Bifurcation involvement.
Internal –ve.
Widening of periodontal membrane space at periapical.
Calcific mass in pulp.
7-mobility or fistulus tract.

19. Evaluation:
-After 6-8 weeks, evaluate treated tooth for success of treatment (criteria of success of treatment)
1-restoration is intact
2-absence of adverse clinical sign & symptoms:
a- pain b-swelling c-mobility d- sensitivity to percussion e-tooth still vital
3-radiographic evidence of favorable responses
R.O as an evidence of sclerosis & remineralization
Decrease pulp size → reparative dentine formation
No abnormal root or radicular diseases.

20. Direct pulp capping -Definition:
It is the procedure of covering exposed vital pulp using capping material to promote healing & preserve pulp integrity and vitality.
-Advantages:
1-preserve vitality
2-Saves tooth structure & tooth integrity
3-Arrests activity of caries process by scaling off and destroying microorganisms
4-Promotes reparative dentine formation

21. -Indications: (DPC).
1- Limited to traumatic exposure i.e. iatrogenic in isolated field
2-Small pin –point (< 1mm) non hemorrhagic, surrounded by sound dentine
3-Recent exposure; the patient reported immediately or within 2-6 hours
4-Vital pulp with no sign of painful pulpities
5-No or min bleeding
6-Normal radio findings
7-Normal physical condition of patient
8-Open or closed apices (open > close)

22. Contraindications: (DPC).
1- Aged pulp
The success of pulp capping depends on the presence of young active U.M.Cs which is induced odontoblastes which form secondary dentine .
2-abnormal radiographic finding
-Internal or external
-Radiolucent finding
-Bifurcation involvement
-Calcfic mass in pulp
-Abnormal widning of periodontal

23. Follow contraind. Of (DPC).
3-Non vital pulp
4-Mobility or vistula tract
5-Tooth affected beyond repair
6-History of spontaneous pain

24. Pulpotomy -Definition:
It is the complete amputation of coronal pulp tissues till the entrance of radicular pulp followed by medicated placement over radicular pulp to stimulate repair and reserve the remaining vital radicular pulp.
 -Advantages:
Prserve tooth till normal shedding
Highest success rate (98%)
Easness of treatment
Economic
Single visit technique

25. Indications of pulputomy :
1-Carious or traumatic exposure in vital primary teeth when
-Exposure size > 1 mm (pin point)
-Slight bleeding considered normal
2-Restorable tooth
3-No history of spontaneous or persistant pain
4-Normal radio. Findings
No internal –ve
No interradicular bone loss
No widening of lamina dura

26. Follow indication of pulptomy:
5-No abscess ''vital'', no sinus ''no mobility''
6-Clinical signs of normal pulp canals i.e controlled bleeding with direct pressure
7-Good physical condition

27. Contraindications of pulpotomy :
1-Clinical signs of:
Hg. not controlled by direct P following pulp (coronal) amputation
Necrotic pulp or pus discharge
Fistulus tract
Mobility
Swelling
Pain on percussion
2-Radio. Signs of:
Periapical or inter radicular R.L
Internal –ve
Advanced external –ve
3-Chronically ill child (cardiac patients) ''poor physical condition''

28. Technique: 1- Diagnostic set 2-L.A 3-Rubber dam
A) Materials:
1- Diagnostic set
2-L.A
3-Rubber dam
4-High speed pear or fissure bur for cavity pressure
5-Low speed long shank round (rose -head) bur no4 or 5
6-Spoon excavator (sharp)
7-materials used in vital pulp cont.

29. According to material used, pulpotomy is classified into:
Formocresol pulpotomy
Ca(OH)2 pulpotomy
Gluteraldhyde pulpotomy
Ferric Sulphate pulpotomy
Devitalization pulpotomy (paraformaldehyde)
Laser pulpotomy
Electrosurgry pulpotomy
Other experimental material:
BMP
MTA
Freezed dried bone

30. Formocresol pulpotomy:
One step technique
Criteria for single visit :
1-No pain (proper analgesia)
2-No blood oozing
3-Cooperative child
4-Enough time.
Cotton pellets moistened with 1/5 dilution formocresol
Remove excess of formocresol by dapping on cotton roll
Place over orifices of R.C for 3-5 mins → dark brown orifices with min oozing of blood
Zno/E pastes placed over pulp stumps and tapped gently
Final restoration ''st.st & amalgum''

31. 2 steps technique:
-Why?
1- If no sufficient time to finish in first visit
2-Uncooperative child
-Technique:
Same as single visit except:
Place cotton pellet with formocresol in the floor of pulp chamber and temporary filling
Second visit after 2-3 days
Remove cotton after isolation with rubber dam (L.A)
Restore in usual manner

32. Indications of formocresol pulpotomy
1-Vital primary tooth with carious or accidental exposure
2-clinical signs of normal pulp canal.
Contraindications
1-spontaneous pain
2-swelling
3-fistula
4-percussion tenderness
5-pathological mobility
6-external or internal root resorption
7-pulp calcifications
8-periapical or interradicular radiolucency
9-profuse hemorrhage
10-exudates

33. Evaluation: Pulpotomy.
1-Asymptomatic tooth
2-No mobility or fistulae
3-No furcation radioucency
4-No internal/external root resorption.

34. Devitalization pulpoyomy (2 steps pulpotomy)
The generally accepted pulp treatment for primary teeth is the formocresol pulpotomy. However in some circumstances single visit formocresol pulpotomy cann't be achived due to:
Insufficient time avalible
Pulpal inflammation makes it difficult to achieve profound analgesia for pulp amutation
Limited patients cooperation.

35. First visit:
The technique involves placement of paraformaldehyde paste over the exposed pulp (after being sure that the exposure site free of debris) & sealed for 1-2 weeks using quick set Zno/E
Second visit:
No local anesthesias, isolate, remove dressing & paraformaldehyde paste and inspect if no sensitivity or bleeding from exposure site, procedure in usual manner (3-6 formocresol pulpotomy)

36. -Indications 1- Small exposure
Calcium Hydroxide pulpotomy
-Indications
1- Small exposure
2- The patient reported late within less than 12 hours
3- Large exposure & patien reported immediate
4- Vital tooth with no symptoms of painful pulpities
5- Incompletely formed roots (open apices)

37. -Non-vital pulp therapy for primary teeth
 Non-vital pulpotomy ''mortal pulotomy''
Ideally a non vital tooth should be treated by pulpectomy and root canal filling.
-Technique:
First visit
-Necrotic coronal pulp is removed as pulpotomy & infected radicular pulp is treated with strong antiseptic solution.
→ formocresol
→Comforated monochlorophenol (CMP)
-Material is applied on cotton pledget & sealed in pulp for 1-2 weeks.
-Strong antiseptic action of these solutions combats infection in radicular pulp.

38. Second visit
Antiseptic solution is removed & replaced by antiseptic paste (Eudenol, formocresol & zinc oxide powder)
Press antiseptic paste firmly into root canal with a cotton pellet.
Pressure forces paste down root canal compressing pulp tissue apically.
Restore tooth as usual (chrome steel crown).
-presence of sinus with chronic abscess or of some degree of tooth mobility is not a contraindication for this method.
-sinus →expected to disappear following control of infection
Mobile tooth →becomes firm as periapical bone reforms

39. A tooth with acute abscess may be treated by this method after draining pus & controlling infection.
-Failure may be occur → sinus & fistula remains → tooth mobility → extraction
-success in very young children (3years) → no root resorption & healthy child.
-77% success rate after 3 years and follow up

40. Pulpectomy
Pulpectomy is apexified(closed) permanent teeth is conventional root canal (endodontic) treatment for exposed, infected, and/or necrotic teeth to eliminate pulpal and periradicular infection.

41. Indications of pulpectomy :
a- Dry pulp chamber when tooth is opened
b-Accessible root canals
c-Intra- radicular bony involvement without loss of bony support
d-Continued adverse sign and symptoms following pulpotomy ''excessive hemorrhage that is not controlled with damp cotton pellet applied for several minutes''

42. Follow indication of pulpectomy: e-Strategic tooth e
Follow indication of pulpectomy: e-Strategic tooth e.g lower E with necrotic pulp before eruption of lower 6 or lower E with no successor lower 5 so longer retention is required f-Cooperative patient g-In permanent teeth: indicated for a restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified (closed).

43. Contraindication of pulpectomy:
a- Excessive periapical involvement or mobility
b-Excessive root resorption
c-Excessive internal resorption (perforate bifurcation)
d-Chronically ill child ''congenital or rheumatic heart disease & children on long term corticosteroid therapy or immunocompromised''
e-Tooth near exfoliation
f-Fear of spread of infection to successor
g-Uncontrolable child

44. -Technique: pulpectomy
1- Local anesthesia
2-rubber dam application (cotton roll & saliva ejector)
3-remove infected carious dentine before entering pulp chamber to avoid intrusion of microorganisms into pulp canals
4-using sterile fissure bur enter pulp chamber through exposure site or at area of the pulp horn, complete deroofing using round bur
5-amputate coronal pulp tissue with a sharp excavator to the end of the orifice of the canal; avoid using bur to avoid perforation of bifurcation area
6-the root canals are debrided and shaped with hand or rotary files

45. 7-instrumentation and irrigation with an inert solution alone cannot adequately reduce the microbial population in a root canal system. So disinfection with irrigants such as 1% sodium hypochlorite and/or chlorhexidine is an important step in assuring optimal bacterial decontamination of the canals.
N.B: sodium hypochlorite must not be extruded beyond the apex.
8-after the canals are dried, a resorbable material such as:
-non reinforced Zinc/oxide eugenol,
-iodoform- based paste (KRI),
Or a combination paste of iodoform and calcium hydroxide (Vitapex ,Endflax) is used to fill the canals.

46. 9-root canal obliterating equipment:
-Follow technique of pulpectomy:
9-root canal obliterating equipment:
Lentulo spiral method (lentulo spiral)
Master point method (additional glass slab, root canal plunger)
Pressure syringe method (pressure syringe, barrel syringe, screw type plunger, 2 wrench)
10-The tooth is restored with a restoration that seals the tooth from microleakage.

47. Vital pulp therapy for young permanent teeth
 Partial pulpotomy for carious exposure:
 Procedure:
-inflamed pulp tissues are removed to a depth of 1-3 mm or deeper to reach healthy pulp tissues.
- control pulp bleeding & irrigation with saline , Nahcl
- MTA or Ca(OH)2 capping
- Restoration

48. Indications: Vital tooth Open apex Exposure more than 2 mm
No history of spontaneous pain
1-2 min. enough to control bleeding

49. Objectives: Preservation of pulp vitality
Preservation of tooth integrity
Promote reparative dentine formation
Promote normal physiological root development apex closure.
 Favorable sign &symptoms:
No post operative pain
No post operative swelling
No radiographic evidence of internal resorption, external resortion or calcification
Root completion.

50. Apexogenesis : Definition:
Apexogenesis is a histological term used to describe the continued physiological development and formation of the root's apex.
Removal of pulp tissues till level of C.E.J in pulp chamber, preserving the radicular pulp, promoting normal apical closure
N.B: indirect pulp capping or direct pulp capping or partial pulpotomy all are considered apexogenesis .

51. Apexogenesis : Indication:
Treatment of young permanent teeth with carious exposure.
Exposed teeth with no symptoms of painful pulpitis.
Pulp exposure resulting from crown fracture.
Permanent teeth with immature root develop- -ment but with healthy pulp tissue.
Good physical condition of the patient.

52. Method ( apexiogrnsis).
Ca(OH)2 placed directly on radicular pulp stump stimulates a calcific response immediately adjacent to it, then cement base then final restoration.
This is seen later on as radiographic ''bridge'' over amputation site.
Degenerative & irreversible coronal pulp changes have not progressed into radicular pulp →successful root closure, then endo treated immediately '' if Ca(OH)2 left long; degenerative calcification''

53. A periodic radiograph should be taken to confirm that no pathologic periapical changes are present, also periodic clinical evaluation is mandatory
Complications:
Although high success rate of Ca(OH)2 pulp has been reported (95%)
1- Internal resorbtion
2- Canal calcification
3- Pulp necrosis & abscess

54. Apexification (root end closure in non vital tooth)
 Definition:
Apexification
is a method of treatment for immature permanent teeth in which root growth and development ceased due to pulp necrosis, by removing the coronal and non vital radicular tissue just short of the root end and placing a biocompatible agent such as calcium hydroxide in the canals. The purpose is to allow the formation of an apical barrier.

55. Indications of apexification:
If a young permanent tooth has a pulp with extensive degeneration or necrosis:
A-pulp should be totally debribed.
B-canal is treated with Ca(OH)2 ''direct contact with vital tissue''
Apexification is used to promote root elongation &/or a calcific root closure.

56. Procedure:
In apexification, entire pulp contents are removed to level of radiographic apex using endodontic (broaches & files).
Ca(OH)2 is placed at apical end of radicular canal → gradually washes out → must be replaced every several months (3 month) till apical closure occurs.
A conventional endodontic procedure is done after apexification is complete.

57. Radiographic evidence shouldn't be seen:
1-External root resortion
2-lateral root pathosis
3-Root fracture
4-Breakdown of periradicular supporting tissues during or following therapy
Outcomes of apexification after 6 month
1- Normal closure of canal & apex with normal radiographic application
2- Dome shape apical closure with canal retained BB application
No apparent radio change but closure can be felt as +ve stop clinically using plugger

58. Key factor of success of apexification 1- Proper infection control
2- Proper debridement
3- Proper cronal seal
4-Proper apical seal
Material used should have osteo-inductive property
1- Ca(OH)2
2- CMCP
3- Vitapex
4- Pulpdent
5- BMP
6-MTA

59. Drawbacks of apexicification
Drawbacks of apexicification
1- Long course of treatment .
2- Need patient cooperation.
3- Decrease fracture resistance.
4- Coronal leakage → decrease success rate .

60. Failures following vital pulp therapy
Causes of failure:
Pre- operative causes:
-Misdiagnosis
-Improper case selection ''poor prognosis''
Operative causes:
-Iatrogenic errors
-Perforations
-Ledges
-Longitudinal fracture
Post-operative causes:
-Improper selection of restorable material
-Trauma
-Fracture

61. Criteria of failure: Clinical Radiographic:
Increase periapical or bifurcation radiolucent
Increase intraligmental space
Loss of lamina dura
Root resorption
Clinical
Persistant symptoms
Sinus
Pain on percussion
Mobility.

62. Thank you for your attention…..