PD 240 Pediatric Dentistry Final 2 Study Guide

Vital Pulp Therapies: 1. Indirect Pulp Cap in Young Permanent Teeth - caries removed with exception of that directly overlying pulp, which if removed -> pulp exposure • Protective material placed on thin partition of remaining dentin over pulp with expectation that secondary dentin laid down beneath that area, + tooth will remain vital

- Procedure in which all caries removed with exception of that directly overlying pulp, which if removed would possibly result in pulp exposure • Protective material, which provides good seal, is then placed on thin partition of remaining dentin over pulp with expectation that secondary dentin will be laid down beneath that area, + tooth will remain vital

Module: Pulp Therapy for Primary + Permanent Teeth 1. Pulp 2. Primary Tooth Pulp • Ribbon like • Multiple extensions into accessory canals • Cellular components -> resorption • Pulpal insults -> accelerated resorption

1. Pulp 2. Primary Tooth Pulp • Pulpal conditions different in primary + permanent teeth, with different goals, priorities, outcomes • Primary tooth pulp = anatomically + functionally distinct than permanent tooth Primary pulp: ribbon-like, with multiple extensions into accessory canals • Cellular components play a significant role in physiologic resorption of tooth during mixed dentition phase, + pulpal insults -> accelerated resorption of primary tooth

Medicaments + Other Materials Used in Pulpal Therapy 2. Zinc Oxide + Eugenol (ZOE) Materials

- an obtundent (sedative) + effective insulator -> forms a good seal to prevent leakage, salivary contamination + pulpal degeneration Characteristics: • Bactericidal properties due to HYGROSCOPIC property (Removes moisture from substrate) • NOT IRRITATING to pulp (near-neutral pH) • High concentrations of Eugenol -> toxic to tissue Use: A. Fill root canals of pulpectomized primary teeth because it's highly absorbable • Doesn't set to hard consistency -> not good restorative material • Absorbs at similar rate as primary tooth structure though incorporated radio-opaquing agent (barium sulfate) may persist for some time after absorption of ZOE • This hasn't been shown to cause any complications B. Reinforced zinc oxide/eugenol (IRM) can be used as a temporary restoration for caries control in primary teeth • Used in pulpotomy procedure in primary teeth to seal fixed pulp stumps of radicular canals • Its set = hastened in presence of moisture i. Zinc oxide + eugenol = often reinforced with hardening agents in commercial preparations • Most common reinforced preparation on market: IRM by Caulk • Studies: Reinforced material has ability to prevent in-growth of bacteria • Why: good seal or its bacterial inhibitory properties or both C. IRM not used for radicular canals in pulpectomy procedure in primary teeth because its incorporated hardening agents make it less absorbable as treated primary tooth resorbs in prep for eruption of underlying permanent tooth • May be used to provide a coronal seal in pulpectomy procedure, following placement of ZOE paste in radicular canals

Vital Pulp Therapies - Young Permanent Teeth Apexogenesis - histological term used to describe continued physiologic development + formation of root's apex; NOT A PROCEDURE For: Pulp capping (direct + indirect), partial pulpotomy (Cvek Pulpo + trauma), Pulpotomy

- histological term used to describe continued physiologic development + formation of root's apex • Apexogenesis in vital, young, permanent teeth accomplished by implementing appropriate vital pulp therapy described in this section (i.e., indirect pulp capping, direct pulpcapping, and pulpotomy procedure). • NOT a procedure, but a desirable outcome of treatment

Medicaments + Other Materials Used in Pulpal Therapy 3. Vitapex (Pre-mixed Calcium Hydroxide + Iodoform Paste) - intra-canal medicament used in pulpectomized primary teeth • Paste composed of calcium hydroxide + iodoform • High pH of calcium hydroxide neutralizes endotoxins produced by anaerobic bacteria + iodoform paste serves as bacteriostatic agent while increasing radio-opacity of medicament • Doesn't harden + absorbs with physiologic resorption of primary roots • Stimulates hard tissue formation of surrounding alveolar bone After placement of Vitapex in root canal space, pulp chamber may be filled with GI or IRM + then tooth should be restored with crown to prevent microleakage + fracture/loss of coronal tooth structure

- intra-canal medicament used in pulpectomized primary teeth • Paste composed of calcium hydroxide + iodoform • High pH of calcium hydroxide neutralizes endotoxins produced by anaerobic bacteria + iodoform paste serves as bacteriostatic agent while increasing radio-opacity of medicament • Doesn't harden + it absorbs with physiologic resorption of primary roots • It stimulates hard tissue formation of surrounding alveolar bone After placement of Vitapex in root canal space, pulp chamber may be filled with GI or IRM + then tooth should be restored with crown to prevent microleakage + fracture/loss of coronal tooth structure

Vital Pulp Therapies: 2. Direct Pulp Cap in Young Permanent Teeth - minimally exposed pulp protected by means of biocompatible material placed over exposure + seal against ingress of bacteria or their byproducts -> pulp to recover + maintain its normal vitality + function

- minimally exposed pulp protected by means of biocompatible material placed over exposure + seal against ingress of bacteria or their byproducts, allowing pulp to recover + maintain its normal vitality + function • This technique SHOULDN'T be used in primary teeth, with very specific exceptions

Medicaments + Other Materials Used in Pulpal Therapy 6. Ethylene-Diaminetetraacetic Acid (EDTA)

- polyamino carboxylic acid + used to remove inorganic debris + smear layer from inner radicular dentin in pulpal regeneration/revascularization procedures • Exposes mediator factors from dentin walls of pulp canal that attract multipotent (stem) cells from apical papilla + stimulate their differentiation Peds Clinic: Use EDTA in a liquid formulation for this purpose

Medicaments + Other Materials Used in Pulpal Therapy 1. Mineral Trioxide Aggregate (MTA) - powder of hydrophilic particles that sets in presence of moisture into a hard structure • Highly biocompatible, provoking little or no inflammatory response from pulp, + forms a good seal once set • Animal studies: inductive effect on CEMENTOBLASTS • Component: BISMUTH -> create dark stain within treated teeth over time Use: • Placed over pulp exposure in direct pulp caps + over amputation stumps in apexogenesis in permanent teeth • Collagen plug, to create an apical stop in Apexification technique • In pulpal regeneration technique MTA = used to create a coronal seal over stimulated blood clot which fills sterilized radicular canal Study: MTA effective material for use in primary tooth pulpotomies, + AAPD Guidelines now cite equivalent results using this medicament as compared to formocresol pulpotomies Future: To replace MTA • Newer bioceramic materials: Biocompatible + DON'T result in staining of treated tooth, but no strong evidence yet

- powder of hydrophilic particles that sets in presence of moisture into a hard structure • It's highly biocompatible, provoking little or no inflammatory response from pulp, + forms a good seal once set • In animal studies, it has been shown to have an inductive effect on cementoblasts • Because one of its components is bismuth, it tends to create a dark stain within treated teeth over time. Placed over pulp exposure in direct pulp caps + over amputation stumps in apexogenesis in permanent teeth • Additionally, it is used over a collagen plug, to create an apical stop in Apexification technique • In pulpal regeneration technique MTA = used to create a coronal seal over stimulated blood clot which fills sterilized radicular canal Study: Current research strongly suggests that MTA is be an effective material for use in primary tooth pulpotomies, + AAPD Guidelines now cite equivalent results using this medicament as compared to formocresol pulpotomies • Newer bioceramic materials = showing promise clinically in place of MTA, as they seem to be biocompatible + DON'T result in staining of treated tooth, but to date there's limited strong clinical trial evidence available for their efficacy

Tetanus

- serious disease caused by a toxin made by spores of bacteria, Clostridium tetani, found in soil, dust + animal feces Pathogenesis: • When spores enter a deep flesh wound, they grow into bacteria that can produce a powerful toxin, tetanospasmin • Toxin impairs nerves that control muscles (motor neurons) -> painful muscle contractions, particularly of jaw + neck muscles • Tetanus can interfere with patient ability to breathe + can be life threatening. Commonly known as "lockjaw." • Patients who have a WOUND POTENTIALLY CONTAMINATED WITH SOIL = AT RISK • Nearly all cases of tetanus occur in people who have never been vaccinated or in adults who haven't kept up with their 10-year booster shots Signs + symptoms: • Appear anytime from a few days to several weeks after tetanus bacteria enter body through wound Average incubation period: 7-10 days Vaccines: • DTaP (Diphtheria, Pertussis & Tetanus) • DT (Diphtheria & Tetanus): For children < 7 with allergic reaction to Pertussis vaccine • Td (Tetanus & Diphtheria): For anyone > 7 Immunization Schedule: • Children should get 5 doses of DTaP, 1 dose at each of following ages: 2, 4, 6, + 15-18 months and 4-6 years (know) • DT doesn't contain Pertussis, + used as a substitute for DTaP for children who cannot tolerate Pertussis vaccine. • Booster (Td) given at age 11-12, then every 10 years subsequent to last dose. Emergency Care: • Any adult receiving care for a dirty wound or injury which breaks skin = usually given a booster (Td) if last booster was given more than 5 years prior to injury • Booster should to be given within 48 hours after trauma

2. Pulpotomy for Primary Teeth - removal of CORONAL pulp + seal of healthy (vital) radicular pulp stumps -> healing of radicular pulp For: Pulpal degeneration not progressed BEYOND CORONAL PULP TISSUE + RADICULAR PULP TISSUE HEALTHY (tooth = vital) Goal: Maintain expected lifespan of treated tooth • Preserves tooth as functional unit + space maintainer within dental arch until normal exfoliation of that tooth occurs PEDS CLINIC: Transitioning away from formocresol to MTA Success dependent on presence of vital pulp tissue in radicular canals: • Best assessed clinically by ability to achieve hemostasis of root stumps with moist cotton pellet, prior to placing any medicament • Inability to achieve hemostasis of pulp stumps suggests that radicular pulpal tissue inflamed + may become non-vital causing failure of pulpotomy technique • Radicular pulp tissue which doesn't bleed or necrotic odor -> non-vital -> pulpotomy procedure isn't appropriate Pulpotomies assessed radiographically + CLINICALLY on yearly basis

- vital pulp procedure that removes compromised coronal pulp tissue + preserves vital radicular pulp tissue For: pulpal degeneration hasn't progressed BEYOND CORONAL PULP TISSUE + RADICULAR PULP TISSUE REMAINS HEALTHY (i.e. tooth = vital) Goal: Maintain expected lifespan of treated tooth • Preserves tooth as a functional unit + space maintainer within dental arch until normal exfoliation of that tooth occurs • Coronal pulp tissue that has an unknown degree of bacterial contamination, inflammation + degeneration, is amputated, hemostasis is achieved with direct pressure, + medicament placed over radicular pulp stumps, where pulpal tissue is more likely to be unaffected Indicated for VITAL primary teeth • Area to be healed at amputation site = relatively small with proportionally greater blood supply compared to conditions at exposure site • Amputation site = adjacent to sound uncontaminated dentin, whereas dentin at exposure site may exhibit varying degrees of destruction + bacterial contamination General pulpotomy procedure can utilize either formocresol or MTA PEDS CLINIC: Transitioning away from formocresol to MTA IMPORTANT NOTE: Once pulp of tooth accessed, ONLY STERILE WATER used for irrigation to reduce risk of systemic infection from water borne pathogens Success of pulpotomy (formocresol or MTA) dependent on presence of vital pulp tissue in radicular canals • Best assessed clinically by ability to achieve hemostasis of root stumps with moist cotton pellet, prior to placing any medicament • Inability to achieve hemostasis of pulp stumps suggests that radicular pulpal tissue inflamed + may become non-vital causing failure of pulpotomy technique • Radicular pulp tissue which doesn't bleed, and/or has a necrotic odor -> non-vital -> pulpotomy procedure isn't appropriate Recommended that pulpotomies be assessed radiographically on a yearly basis • Clinical assessment (patient report, direct visual + radiographic evaluation) should also be undertaken on a yearly basis to confirm continued tooth vitality

Pulpal Regeneration Technique 1. Access necrotic pulp 2. Irrigate copiously into apical 1/3 of canal with 1-2.5% sodium hypochlorite (leaves vital tissue intact, dissolves & disinfects necrotic tissue) until canal stops draining + smells clean • Dry with paper points.

1. Access necrotic pulp 2. Irrigate copiously into apical third of canal with 1-2.5% sodium hypochlorite (leaves vital tissue intact, dissolves & disinfects necrotic tissue) until canal stops draining + smells clean • Dry with paper points.

Young Permanent Teeth Apexification Follow steps for pulpectomy (extirpate entire pulp) Irrigate with sodium hypohclorite Clean, dry with paper points APICAL COLLAGEN MATRIX MTA (+ moist pellet x24 hrs) After 24 hrs re-open, check MTA Place gutta percha Need pre-op + post-op radiograph 6 month recall check

1. Extirpate coronal + radicular pulp tissue. 2. Irrigate with sodium hypochlorite, dry canals with paper points 3. Place apical collagen plug to create an immediate apical stop 4. Place MTA (minimum 3mm) over collagen plug to produce a permanent seal at apex, place moist cotton pellet + temporarily seal canal 5. Check set of MTA in 24 hours • After confirming set, fill with gutta-percha (final RCT) + monitor for periapical healing 6. Before dismissing the patient, secure 2 radiographs: a post-op PA of involved tooth + bitewing film of this area (if a posterior tooth) • Used for future comparison. 7. Recall patient in 6 months + evaluate periapical health of treated tooth • Take PA + bite-wing of treated tooth • Examine radiographs for apical integrity of tooth, + compare with previous radiographs to note any possible degenerative changes

Young Vital Permanent Teeth Pulpotomy Technique 1. Access pulp chamber + extirpate coronal pulp 2. Irrigate with saline 3. Control bleeding 4. Place MTA over amputated stump (s) 5. Cover MTA + surrounding tooth structure with GI for seal 6. Need pre-op + post-op radiographs 7. Check in 6 months for continued root development + closure of apex 8. Final restoration can be placed but further tx may be needed Ideal restoration: SSC

1. Extirpate coronal pulp + achieve hemostasis of pulp stumps using cotton pellet moistened with water + direct pressure • Confirm hemostasis (= healthy radicular pulp tissue) 2. Place MTA over amputated radicular pulp stump(s) NOTE that formocresol is NOT used in pulpotomies in young permanent teeth! 3. MTA + surrounding tooth structure covered with GI material to seal radicular pulp stumps 4. Final restoration can often be placed, once apexogenesis achieved, but patient/parent should be informed that additional treatment may be needed in future 5. Before dismissing patient, secure 2 radiographs: 1. Post-op PA of involved tooth 2. Bitewing film of this area (if posterior tooth). • Used for future comparison 6. Recall patient in 6 months + check status of treated tooth • Take PA + bitewing radiograph of involved tooth • Examine film for completion (maturity) of root apex, + compare with previous films for possible degenerative changes • If root apex appears mature + tooth has been asymptomatic, place final restoration, if this has not been done previously • Otherwise, recheck again in 6 months. 7. Treated teeth should continue to be clinically evaluated at subsequent recall appointments, however radiographs may not be indicated at each recall if tooth remains asymptomatic + no other clinical findings suggest failure

Pulp Therapy - Young Permanent Teeth Common Clinical Mistakes

1. Failure to recognize & correlate clinical, radiographic, + patient history factors when deciding pulp therapy -> inadequate/failed treatment 2. Failure to distinguish appropriate management of young permanent teeth + primary teeth. 3. Inadequate understanding of medicaments + materials used + incorrect selection of same 4. Failed isolation of tooth receiving pulp therapy -> re-infection + failure of pulp therapy, with possible loss of tooth as a consequence 5. Inappropriate restoration of tooth following pulp therapy

Pulp Therapy - Primary Teeth Common Clinical Mistakes

1. Failure: A. Recognize & correlate clinical, radiographic, + patient history factors when deciding pulp therapy -> inadequate/failed treatment B. Distinguish appropriate management of primary teeth + young permanent teeth C. Failure to accurately assess signs of inflammation of radicular pulp stumps during pulpotomy procedure - may not recognize involvement of radicular pulp tissue -> pulpotomy failure 2. Incomplete removal of pulpal tissue from pulp chamber in pulpotomy procedure -> re-infection of radicular pulp, failure of pulpotomy, loss of tooth 3. Incorrect restoration of pulpotomized/pulpectomized primary tooth -> tooth fracture usually requiring extraction + space maintenance

Pulpectomy Factors 1. General Health of Patient: Immunocompromised or at risk of Bacterial Sepsis 2. Tooth Involved: A. Non-vital primary anterior teeth: EASIER, CONICAL CANAL Cause: Trauma B. Non-vital primary molars: more complex Cause: Caries Purpose: • Terminal tooth in arch + needed to guide eruption of permanent 1st molars in lieu of distal shoe space maintenance appliance • Because success rate variable in primary molars, + failed pulpectomy may result in damage to a developing permanent successor, EXTRACTION + SPACE MAINTENANCE often preferred treatment when primary tooth isn't terminal tooth in arch, prior to eruption of an adjacent permanent molar 3. "Restorability" of tooth once pulp therapy completed + prognosis for survival of restoration Guarded Prognosis: shortened lifespan of tooth • Unrestorable or poor lifespan post restoration -> not worth 4. Dental Developmental Status • More critical to preserve a primary molar during period of primary dentition than subsequent to eruption of 1st permanent molar Why: Early loss of primary molar necessitates placement of a space maintainer pending eruption of underlying permanent tooth A. Save Primary 2nd molar Why: • Loss of 2nd primary molar in primary dentition requires fabrication + placement of an intra-alveolar distal shoe space maintainer -> more difficult to fabricate + more susceptible to problems than other types • Because of this, preservation of a NON-VITAL 2ND PRIMARY MOLAR prior to eruption of 1st permanent molar critical, even if only until adjacent permanent molar erupts • As primary molars "age" -> increased deposition of secondary dentin in canals creating irregular islands of dentin along canal walls, which can make instrumentation difficult • This must be considered when deciding on pulpectomy procedures performed in primary teeth during mixed dentition stage 5. Difficult intra-radicular anatomy (ribbon-shaped - hard to clean)

1. General Health of Patient • Immunocompromised or at risk of bacterial sepsis (SBE, etc.) -> NOT candidate for pulpectomy procedure, as failure of pulpectomy -> septicemia or other dire consequences 2. Tooth Involved A. Non-vital primary anterior teeth • Can readily be treated with pulpectomy due to presence of only a single canal, size + configuration of canal + ease of access • Generally primary anterior teeth become devitalized as a result of trauma rather than caries which is primary cause among primary posterior teeth B. Non-vital primary molars • Considered for pulpectomy when they're terminal tooth in arch + needed to guide eruption of permanent 1st molars in lieu of distal shoe space maintenance appliance • Because success rate of this procedure variable in primary molars, + failed pulpectomy may result in damage to a developing permanent successor, extraction + space maintenance is often preferred treatment when primary tooth isn't terminal tooth in arch, prior to eruption of an adjacent permanent molar 3. "Restorability" of tooth once pulp therapy completed + prognosis for survival of restoration • If tooth unrestorable or will not have an acceptable lifespan post restoration, pulpectomy may not be appropriate 4. Dental Developmental Status • Generally more critical to preserve a primary molar during period of primary dentition than subsequent to eruption of 1st permanent molar • Early loss of primary molar necessitates placement of a space maintainer pending eruption of underlying permanent tooth • Loss of a 2nd primary molar in primary dentition requires fabrication + placement of an intra-alveolar distal shoe space maintainer • This type of space maintainer somewhat more difficult to fabricate + more susceptible to problems than other types • Because of this, preservation of a non-vital 2nd primary molar prior to eruption of 1st permanent molar critical, even if only until adjacent permanent molar erupts • As primary molars "age" -> increased deposition of secondary dentin in canals creating irregular islands of dentin along canal walls, which can make instrumentation difficult • This must be considered when deciding on pulpectomy procedures performed in primary teeth during mixed dentition stage

Pulpotomy for Primary Teeth Contraindications 1. IMMUNOCOMPROMISED/at risk of BACTERIAL SEPSIS (SBE, etc.) 2. History of SPONTANEOUS PAIN* (patient waking from pain) * Study: measuring cytokines associated with inflammatory process in primary tooth pulps with carious pulp exposures -> ability to achieve hemostasis not well correlated to actual pulpal health 3. Presence of localized or facial SWELLING (parulis, sinus tract, cellulitis)* 4. EXCESSIVE BLEEDING from radicular canals 5. Extremely DARK COLORED* blood (poorly oxgenated) 6. NECROTIC or ABSENT radicular pulp* 7. Extensive radiographic furcation involvement 8. Unrestorable teeth

1. IMMUNOCOMPROMISED or at risk of BACTERIAL SEPSIS (SBE, etc.) 2. History of SPONTANEOUS PAIN* 3. Presence of localized or facial SWELLING (parulis, sinus tract, cellulitis)* 4. EXCESSIVE BLEEDING from root canals once coronal portion of pulp amputated. (Excessive bleeding - not controlled by direct pressure with moistened [water] cotton pellets in 2-3 minutes) * Note that a recent study measuring cytokines associated with inflammatory process in primary tooth pulps with carious pulp exposures suggests that ability to achieve hemostasis may not be well correlated to actual pulpal health. [Mutluay 2018] 5. Pulpal blood that is extremely DARK COLORED* 6. NECROTIC or ABSENT radicular pulp* *These contraindications for a pulpotomy are indications for pulpectomy, or more commonly extraction (depending on the severity of the case, the tooth involved, and/or the dental development of the patient).

Pulpal Pathology Cascade

1. Irreversible pulpitis 2. Pulpal necrosis 3. Furcation involvement 4. Parulis (symptomatic) 5. Sinus tract (can be asymptomatic)

Main steps to follow during an emergency visit:

1. Obtain an Accurate History: Medical Hx & Dental Hx 2. Trauma History 3. Consciousness assessment 4. Extra-oral exam 5. Intra-oral exam 6. Radiographic assessment 7. Provide emergency treatment 8. Follow-up visits + discuss prognosis 9. Documentation

Young Permanent Teeth Direct Pulp Cap Technique

1. Prepare cavity + make all extensions before removing bulk of deep caries • Carefully excavate remaining decay with large, sharp spoon excavator or a #4 to 6 round bur, in low speed handpiece 2. If pulp exposed + requisites of direct pulp capping met, apply cotton pellet moistened with water or normal saline to clean exposure + stop bleeding • Dry with cotton pellets • If vital exposure measures > 1mm in diameter, decide whether more extensive endo procedures will be required 3. Apply mineral trioxide aggregate (MTA) over exposure 4. Cover MTA + remaining deep exposed dentin surrounding it with GI material • Essential that GI material completely seal over area of exposure to protect underlying pulp from ingress of bacteria or their byproducts 5. Place a restoration • If a temporary restoration intended, IRM works well • In cases where exposed pulp appears to be healthy + good seal obtained with GI, a final restoration can be considered, but patient + parent should be informed that there's a possibility that pulp cap will not be successful, + that further treatment of tooth will be necessary should that occur

Young Permanent Teeth Indirect Pulp Capping Technique

1. Prepare cavity + make all necessary extensions before removing bulk of deep caries. • With high-speed bur -> remove all unsupported enamel surrounding + overlying carious dentin -> provides easy access to lesion • With large round bur (# 4 or 6), slowly rotating, or with a sharp, large spoon excavator with a "raking" motion, remove all caries except that immediately overlying pulp 2. Place a layer of GI material, covering all exposed dentin • Goal of this material = seal dentin over area of near exposure to prevent ingress of bacteria or their byproducts, thus allowing pulp tissue to heal 3. In cases where dentin under indirect pulp cap relatively sound, + good seal has been obtained with pulp capping material, a final restoration can often be placed • Patient + parents should be informed that there's possibility that pulp cap will not be successful, + that tooth may need further treatment should that occur • If an exposure = found, a direct pulp cap can be attempted, or further endo therapy may be recommended

Young Permanent Teeth Direct Pulp Cap Technique Summary (Know)

1. Prepare cavity, make all extensions before removing deep caries 2. Carefully excavate caries 3. If "pin-point" exposure 4. Clean + dry exposure 5. Apply MTA over exposure 6. Place GI material over MTA A. Place temporary restoration for at least 6 months i. Re-entrance in 6 months to 1 year, place GI material + final restoration B. If pulp tissue under cap = healthy + good seal has been obtained, consider final restoration of tooth • Advise patient/parent of possibility of additional treatment needs

Young Permanent Teeth Indirect Pulp Capping Technique Summary 1. Prepare cavity + make all necessary extensions before removing bulk of deep caries 2. Carefully excavate caries except that immediately overlying pulp 3. If no pulp exposure -> 4. Place GI A. Consider final restoration B. Place temporary restoration for 6 months -> re-access in 6 months place GI + final restoration

1. Prepare cavity, make all extensions, leave deep caries 2. Carefully excavate caries except that immediately overlying pulp 3. If no pulp exposure 4. Place GI A. If significant affected dentin remains or success of cap = questionable, then place temporary restoration for at least 6 MONTHs i. Re-entrance in 6 months- 1 year, place GI material + final restoration B. If dentin under cap relatively sound + good seal has been obtained, consider final restoration of tooth • Advise patient/parent of possibility of additional treatment needs

Characteristics of Traumatic Incidents 1. Primary Dentition

1. Primary Dentition Age: 1.5 - 2* (first steps, developing motor coordination) *This underscores importance of establishing dental home by 1 year of age Displacement (Luxation) injuries more common than fractures: • Short clinical crowns • Less calcified bone • Thin cortical plates 2. Mixed Dentition Age: 8 - 11 (sports related, decreasing parental supervision) *Class II with significant overjet predisposes incisors to traumatic injury Dental fractures more common: • Longer clinical crowns • Bone more dense • Thicker cortical plates

Pulpal Procedure + Indicated Evaluation-Routine (no symptoms of pulp pathology)

1. Primary Tooth Pulpotomy • Yearly radiograph (taken for other indications or specifically to evaluate pulpotomized tooth) • Clinical monitoring at all visits 2. All other pulp therapy procedures • Radiographic evaluation whenever visible on radiographs taken for other indications (no specific radiograph indicated for evaluation) • Clinical monitoring at all visits

Pulpectomy Indications: Pulpal necrosis findings 1. Non-vital primary teeth, ESPECIALLY PRIMARY 2ND MOLARS before eruption of permanent 1st molar *Advantageous to retain terminal tooth in arch (temporarily?- 2. Radiographic evidence of furcation or periapical involvement 3. Soft tissue involvement

1. Pulp tissue observed to be necrotic on entering pulp chamber (in this case it's unlikely that radicular pulp tissue unaffected) 2. Bleeding of radicular pulp stumps can't be controlled once coronal pulp amputated (indicating inflamed, unhealthy radicular pulp tissue) 3. Radiographic evidence of furcation or periapical involvement (infectious process has progressed beyond confines of tooth) 4. Patient report of spontaneous pain, which may keep patient awake at night 5. Soft tissue manifestations of purulent exudate emanating from affected tooth (parulis, sinus tract, drainage from sulcus) 6. Internal resorption. (Prognosis for successful pulpectomy: poor)

Young Permanent Teeth Indirect Pulp Capping Indications Vital pulp Radiographic/clinical probably exposure No history of pain Negative to percussion, no soft tissue involvement, no mobility, bone loss, resorption

1. Radiograph shows that a near or probable pulpal exposure exists 2. No history of prolonged or spontaneous pain, no sensitivity to percussion, no redness or swelling, no mobility, no bone loss, no internal resorption + a definite, positive response to EPT present 3. Good general health

Pulp Therapy For Primary Dentition

1. Reversible Pulpitis • Indirect Pulp Cap (GI liner + restoration) • Pulpotomy (Coronal pulp removed, or MTA) 2. Irreversible Pulpitis/Necrotic (Non-vital Pulp) • Pulpectomy (ZOE or Vitapex) • Extraction + Space Maintainer • Direct Pulp Cap ISN'T recommended for primary dentition • If there is a carious pulp exposure, pulpotomy procedure -> treatment of choice

Young Permanent Dentition: Case Selection - Pulpal Status + Root Formation

1. Reversible Pulpitis -> Pulp Cap or Pulpotomy 2. Irreversible Pulpitis: A. Open Apex i. Apexification ii. Pupal Regeneration B. Closed Apex -> RCT

Young Permanent Teeth Indirect Pulp Cap Advantages

1. Simple to perform 2. Carious dentin that hasn't been completely demineralized can remineralize 3. Bacteria in deeper layers of softened dentin remain dormant when sealed from oral environment 4. Doesn't produce surgical trauma by mechanically invading pulp chamber 5. Doesn't introduce dentin chips + bacteria into pulp iatrogenically 6. Produces more reparative dentin than direct pulp caps or pulpotomy

Pulp Evaluation - Pain Assessment + Implications

1. Suspected Pulpal Pain Pain characteristics: A. Spontaneous, Prolonged, Wakes Patient -> Irreversible Pulpitis i. Extract ii. Non-vital Pulp therapy: Pulpectomy (limited prognosis) B. Provoked, Thermal, Chemical, Mechanical, Intermittent, Doesn't wake patient -> Reversible Pulpitis i. Vital Pulp therapy • Pulp cap (indirect or direct) • Pulpotomy

Young Permanent Teeth Direct Pulp Cap Indications

1. Vital pulp 2. No history of prolonged or spontaneous pain, sensitivity or percussion, redness, swelling, mobility, bone loss or internal resorption 3. Exposure, carious or mechanical, should have been made in a dry field under rubber dam; pulp must not be unduly lacerated or abused while caries being removed 4. Traumatic exposure when seen within a few hours post-accident in teeth with mature roots 5. Small ("PIN-POINT") Exposure - carious, mechanical, traumatic 6. Patient should be in good general health (contraindicated if patient susceptible to infection, ex: bacterial endocarditis) Other: Radiographic/clinical probable exposure Negative to percussion, no soft tissue involvement, no mobility, no bone loss, no resorption

Pulpal Regeneration Technique 3. Inject bi-antibiotic or CaOH paste into chamber, then condense into canals with an endo plugger or large end of a coarse paper point.

3. Inject bi-antibiotic or CaOH paste into chamber, then condense into canals with an endo plugger or large end of a coarse paper point. Tri-antibiotic or bi-antibiotic paste components: A. Ciprofloxacin (200 mg) B. Metronidazole (500 mg) C. Minocycline* (100 mg) • *Minocycline can cause blue/green staining of tooth that can be removed with varying degrees of success, using internal bleaching techniques • Some studies = evaluating effectiveness or a bi- antibiotic paste, while others considering use of CaOH as a disinfecting agent for this procedure D. Propylene glycol carrier PEDS CLINIC: Use a bi-antibiotic paste (ciprofloxacin & metronidazole, omitting minocycline) or calcium hydroxide (CaOH) paste for disinfection of canal space in pulpal regeneration procedures

Pulpal Regeneration Technique 6. Place MTA (3mm thick) over the clot (at level of CEJ) to provide a definitive seal. • Once blood clot arrives to CEJ, place MTA (3mm thick) over clot 7. Place a small layer of GI liner over MTA + restore with a bonded restoration and/or crown

6. Place MTA (3mm thick) over the clot (at level of CEJ) to provide a definitive seal. 7. Place a small layer of GI liner over MTA + restore with a bonded restoration and/or crown • It's essential that coronal aspect of pulp chamber be meticulously sealed to prevent ingress or oral bacteria or bacterial by-products

3. Pain Description of pain important -> it will guide your Dx + Tx recommendations A. Dental pain • Varies, subjective experience • Young children less able to accurately differentiate, describe + even locate pain than their older counterparts • Different pain thresholds B. Pulpal pathosis • CC usually PAIN • Pain can't be used as sole criterion for determining patient's pulpal status; primary pulps can degenerate + become necrotic without pain -> other criteria C. Other non-pulpal factors -> eliminate • Experience pain from wide range of stimuli: residual cement from SSC, recent rubber dam clamp placement, local food or foreign body trauma, etc.

A. Dental pain = subjective experience, varies widely from patient to patient • Patient's ability to communicate + locate pain varies, with young children less able to accurately differentiate, describe + even locate pain than their older counterparts • Individual patients have different pain thresholds as well; some patients = nearly debilitated by relatively low-level pain which may present only an annoyance to other patients with higher pain thresholds • Young patients may interpret any unpleasant sensation as "pain" without differentiating severity, while older children better able to offer these distinctions B. Often patients with pulpal pathosis will present with a chief complaint of pain • Further evaluation of pain offers essential info in diagnosing patient's pathosis + likely health of pulp • It's important to note however that pain can't be used as a sole criterion for determining a patient's pulpal status; primary pulps can degenerate + become necrotic without pain • Pain = only one of criteria which must be evaluated + considered in determining pulpal status of any tooth C. Whenever pain being considered relative to pulpal health, other non-pulpal factors should be eliminated • Patients can experience pain from a wide range of stimuli: residual cement from SSC, recent rubber dam clamp placement, local food or foreign body trauma, etc. • A logical relationship should be determined between patient's symptoms + other pulp evaluation findings + intraoral findings + conditions

3. Immature Permanent Tooth Pulp • Large volume • Little or no intraradicular secondary dentin • Highly cellular + vascular • Apex open, pulp closer to surface • Robust (peri-) Apical papilla (SCAP) - more stem cells

A. Immature permanent tooth pulp distinct from that of mature permanent tooth: • Volume is greater • As little to no intraradicular secondary dentin has formed • Apex of developing permanent tooth isn't yet closed B. Immature permanent tooth pulp: • Highly cellular compared to mature permanent tooth • Apical papilla, surrounding the incomplete apex of immature permanent tooth, = far more robust + contains a larger # of stem cells than its mature permanent tooth counterpart • All of these features must be carefully assessed + properly managed in pulp therapy

Vital Pulp Therapies 1. Pulp Capping for Primary Teeth A. Indirect Pulp Caps • CAUTIOUSLY USED - minute pulp exposure likely. • If used -> adequate seal essential Summary Diagram Image: GI material over near pulp exposure Goal: Obtain apexogenesis, formation of secondary dentin over near exposure + continued vitality of pulp Technique: • Leave deepest caries adjacent to pulp undisturbed • Remaining caries excavated to point where pulp exposure eminent • GI material provides good seal over dentin • Temporary or permanent restoration Notes: Vital pulp = doses have ability to heal

A. Indirect Pulp Caps • Leave deepest caries adjacent to pulp undisturbed to avoid pulp exposure, in teeth whose pulp = judged by clinical + radiographic criteria to be vital + able to heal from carious insult • Remaining caries-affected dentin then covered with a biocompatible material to isolate it from further contamination by providing a good biological seal • Important when considering this technique to carefully evaluate presence of carious pulp exposure • If pulp has likely been cariously exposed, a pulpotomy should be considered Peds Clinic: GI type materials used for indirect pulp capping

Assessment of Traumatic Injuries 1. Get Accurate History

A. Medical History i. Are there any contraindications to treatment? ii. Tetanus* and/or antibiotic coverage necessary? Other: blood disorders, possible allergies, up to date with immunization B. Dental History i. Dental home? ii. History of previous dental trauma?

6. Pulp Testing (EPT, thermal tests) A. Primary Teeth: UNRELIABLE - not able to localize or accurately describe pain sensations + primary pulp response: erratic B. Young permanent teeth: Unreliable • Useful to establish baseline C. Thermal tests for response to hot + cold can be used to determine extent of pulpal pathosis in permanent dentition

A. Primary Teeth: • Electric pulp tests + tests for hot or cold, often unreliable for primary teeth + of relatively little or no value in determining pulpal status Why: Because children, especially young children, may not be able to localize or accurately describe pain sensations • Additionally, primary pulp's response to these forms of stimulation is often erratic, making it difficult to track or to use for basis of diagnostic decisions B. Permanent Teeth: • Electric pulp testing = particularly valuable tool to employ in fully formed (mature) permanent tooth, but it tends to be inconsistent + unreliable in immature permanent tooth • Perception of electrical stimulus by patient supports presence of a vital pulp in mature permanent teeth Thermal tests for response to hot + cold can also be used to determine extent of pulpal pathosis in permanent dentition • Heat test accomplished by applying hot gutta percha stick to tooth • Cold test by applying a cotton pellet saturated with ethyl chloride (Endo Ice®) • Thermal tests provoke a prolonged or lingering response in teeth with degenerating pulps • As with electric pulp testing, this may be less accurate in immature permanent teeth

2. Exam of Soft Tissues A. Pulpal necrosis • Manifest clinically in soft tissues ADJACENT to affected tooth • Tissue: boggy, swollen, inflamed due to purulent exudates from necrotic tooth accumulating in peri-radicular tissues • Exudate will break through alveolar bone + accumulate under soft tissue -> PARULIS ("gum boil") B. Chronic situation • Exudate may penetrate overlying mucosa + drain into ORAL CAVITY -> patent SINUS TRACT -> patient's pain may lessen or disappear until there's a blockage of tract, when pain typically recurs, + parulis can redevelop

A. Pulpal necrosis • Often manifest clinically in soft tissues adjacent to affected tooth • Tissue may become boggy, swollen and/or inflamed due to purulent exudates from necrotic tooth accumulating in peri-radicular tissues • Frequently exudate will break through alveolar bone + accumulate under soft tissue forming a parulis, or in lay terms a "gum boil" B. Chronic situation -> exudate may penetrate overlying mucosa + drain into oral cavity, forming a patent sinus tract • Once a sinus tract forms, patient's pain may lessen or disappear until there's a blockage of tract, when pain typically recurs, + parulis can redevelop

Pulpal Regeneration Technique 5. After bi-antibiotic or CaOH paste in tooth for period of at least 1 month + symptoms resolved, re-access tooth + remove paste using EDTA irrigation • Use an endo explorer or endo file to irritate periapical tissues + stimulate bleeding

After bi-antibiotic or CaOH paste in tooth for period of at least 1 month + symptoms resolved, re-access tooth + remove paste using EDTA irrigation • Use an endo explorer or endo file to irritate periapical tissues + stimulate bleeding into pulp space • Allow bleeding + clot formation to level of CEJ • Level of clot (i.e. the scaffold) critically important as tissue rising to this level will allow continued development of peri cervical dentin (PCD) + enhance strength/prognosis of treated tooth • NOTE: local anesthetic with vasoconstrictors will impede creation of blood clot, so use anesthetics with vasoconstrictors judiciously in order to allow for sufficient bleeding into pulp space

Non-Vital Pulp Therapies - Young Permanent Teeth 1. Apexification with MTA for Young Permanent Teeth - removal of infected coronal + RADICULAR PULP tissue in young permanent teeth, + creation of adequate apical stop to facilitate endodontic fill of canal Indications: • Non-vital pulp of immature permanent teeth (will help retain tooth) • Unsuccessful regeneration of traumatized immature permanent teeth Summary Diagram Image: Core restoration -> gutta percha -> MTA over collagen matrix Incomplete root formation = incomplete apices • Entire pulp (coronal & radicular) removed • No further root development possible • MTA plug creates apical stop for RCT • Crown restoration of choice (often SSC until patient is grown)

Apexification - method of creating an apical stop in root of an incompletely formed (immature), non-vital permanent tooth by removing coronal + non-vital radicular tissue just short of root end and placing a collagen plug + mineral trioxide aggregate (MTA)* in canal *Mineral trioxide aggregate (MTA) has gained acceptance foruse in lieu of calcium hydroxide because of its superior biocompatibility Goal: Creation an adequate apical stop to facilitate obturation of canal with traditional endo methods (gutta percha or root-strengthening procedures) • Because this technique precludes continued maturation of treated tooth, result is a tooth with shortened roots + thin dentinal walls • These factors result in a guarded prognosis for such teeth • Root wall strengthening procedures should be strongly considered in such cases (bonded composite radicular fill). • Research has shown positive results from procedures to revascularize pulp space in young permanent teeth with open (immature) apices -> pulpal regeneration, thus potentially improving their prognosis as compared to teeth treated with traditional apexification

Non-Vital Pulp Therapies - Young Permanent Teeth 2. Pulpal Regeneration for Young Permanent Teeth Pros: 1. Continued "development" of immature permanent tooth 2. Re-establishes vital tissue in radicular canal space Summary Diagram Image: GI over MTA -> MTA -> Residual vital tissue & stem cells from the apical papilla from blood clot (scaffold) & periapex • Immature tooth (open apices), necrotic pulp • Necrotic tissue irrigated away, Canal space disinfected with antibiotic or CaOH paste • Blood clot stimulated, forms scaffold • Cellular in-growth (stem cells from apical papilla), lengthening of root, thickening of radicular walls • Bonded restoration and/or crown restoration of choice Goal: Completed root formation, thickening of radicular walls

Avulsed immature permanent teeth with open apices can be replanted with possibility of revascularization of pulp + attendant continued development of tooth Essential factors for success in replanted teeth seem to be: 1. Open (Immature) Apex-allows reestablishment of vasculature + in-growth of vital tissue into pulp space 2. Uninfected pulp space - no bacteria in vicinity which could infect pulp + cause necrosis 3. Presence of scaffold into which remaining vital tissue can grow (remaining vital cells) 4. Intact crown-prevents. bacterial penetration into pulp space from oral cavity Revascularization of avulsed immature permanent teeth maintains vitality of pulp- dentin complex, which allows continued maturation of traumatized tooth, significantly improving its long term prognosis Theorized that if similar environment could be created in a necrotic, immature permanent tooth with open apices, that revascularization might also occur -> pulpal regeneration Even in necrotic pulp there are some cells which remain vital • Removal of necrotic tissue + disinfection of pulp space, revascularization + proliferation of remaining vital cells along with stem cells from apical papilla (SCAP) which migrate into disinfected pulp space, could result in regeneration of functional pulp- dentin complex • This process modulated by mediator factors from dentin walls of radicular pulp space. • Regeneration of a pulp- dentin complex could lead to continued maturation of immature permanent tooth As compared to apexification, which results in arrested development of immature tooth, pulpal regeneration -> improved prognosis by virtue of fact that tooth could continue to mature -> improving tooth's prognosis.

Formocresol Use Controversy -> Carcinogen since has FORMALDEHYDE: • MTA has equivalent success rates • High success rate + predictable results -> formocresol remains one of standards of care for pulpotomy in primary teeth, when scrupulous + conservative technique used • No conclusive evidence of harm to patient • Alternatives -> Ferric sulfate -> not as good as Formocresol

Because formocresol contains formaldehyde, known carcinogen (International Agency for Research on Cancer, IARC 2004) -> concern over use of formocresol in pulpotomy procedure, + MTA has equivalent success rates • Because of its high success rate + predictable results, formocresol remains one of standards of care for pulpotomy in primary teeth, when scrupulous + conservative technique = used Question of potential harm to patients from formocresol used for pulpotomies has been scientifically evaluated, + continues to be a controversial topic in scientific literature • To date, no conclusive evidence of harm to patients has been shown, + a # of investigators have shown no measurable effects of formocresol outside tooth being treated Because of concern over use of formocresol, an alternative medicament for primary tooth pulpotomies with equivalent success rates + predictability has been sought for years • Several other medicaments have been proposed, most notably ferric sulfate (a hemostatic agent) but clinical trials haven't demonstrated outcomes equivalent to those obtained with formocresol • Large clinical trials have shown MTA pulpotomies to have similar success rates to those done with formocresol, thus MTA is now also considered standard of care for pulpotomies in primary teeth When used in vital primary teeth for pulpotomy procedure, MTA has been shown to preserve normal pulpal architecture + induce thick dentinal bridges with virtually no signs of stimulating inflammation • Theorized that biocompatibility of MTA allows healthy root stumps to heal + remain vital without necessity of chemical cauterization (as provided by formocresol in formocresol pulpotomy procedure)

2. Exam of Soft Tissues C. Primary Teeth Irreversible pulpitis - 1st step toward pulpal necrosis Clinically difficult to distinguish with pulpal necrosis -> terms used synonymously • In immature permanent tooth, due to robust apical papilla, it's possible for tooth to have irreversible pulpitis, which hasn't yet fully progressed to pulpal necrosis D. Cellulitis (symptomatic) • Severity of infection -> extra-oral, diffuse swelling • Defeat infection with a diffuse, instead of a local reaction • Often seen in patients who're immunocompromised, or have multiple foci of infection

C. Primary teeth irreversible pulpitis - 1st step toward pulpal necrosis + pulpal necrosis = clinically difficult, if not impossible to distinguish, thus terms used somewhat synonymously • In immature permanent tooth, due to robust apical papilla, it's possible for tooth to have irreversible pulpitis, which hasn't yet fully progressed to pulpal necrosis D. On occasion, severity of infection may be such that extra-oral, diffuse swelling called "cellulitis," occurs Cause: severity of infection Is such that body attempts to defeat it with a diffuse, instead of a local reaction • This is often seen in patients who're immunocompromised, or have multiple foci of infection

8. Clinical Appearance of Pulp Exposure - Primary vs. Permanent Teeth A. Primary Pulp Horns: Higher + More Pointed Pulp Exposure: • A small area of exposure surrounded by THICK DENTIN -> no halo" or "pink blush" • Initial leakage: May be serous (clear) -> DIFFICULTY TO IDENTIFY 2. Permanent Pulp Horns: ROUNDED Pulp Exposure: Looks like a target • A small area of exposure surrounded by THIN DENTIN -> underlying pulp tissue show through -> "halo" or "pink blush" surrounding actual exposure site. -> easier to identify • Initial leakage: HEMORRHAGIC (red), making it easy to identify

Clinical detection of a mechanical or carious pulp exposure can be more difficult in primary teeth than in permanent teeth • Possible for such primary tooth exposures to go undetected: 1. Primary Pulp Horns • Higher + more pointed than permanent pulp horns • A small area of exposure may be surrounded by a significant area of relatively thick dentin, thus "halo" or "pink blush" which surrounds typical permanent tooth pulp exposure, may be absent in exposure of a primary pulp horn. Initial leakage from a primary pulp exposure may be serous (clear), + thus can be difficult to identify 2. Permanent Pulp Horns • More rounded than primary pulp horns • A small area of exposure usually surrounded by a significant area of relatively thin dentin, which allows underlying pulp tissue to show through • This creates clinical appearance of a "halo" or "pink blush" surrounding actual exposure site, making exposure easier to identify than in primary tooth Initial leakage from a permanent pulp exposure = often hemorrhagic (red), making it easy to identify

3. Pain D. Irreversible Pulpitis - non vital/extraction More severe: Spontaneous, LINGERING (Throbbing), KEEPS CHILD AWAKE without obvious stimuli (food, sweets, cold or hot liquids) Important question: Did toothache wake Johnny up?"

D. Characteristics of patient's pain can offer insights into health of pulp • In absence of other non-pulpal causes, spontaneous, unprovoked pain often evidence of advanced degenerative changes in pulp • Spontaneous nature of this pain = frequently noted through a history of pediatric patient waking from sleep due to pain • Patients often describe this pain as having a lingering, "throbbing" quality -> irreversible pulpitis = often diagnosis, + non-vital pulp therapy (or extraction) = indicated Sidenote: Did toothache wake Johnny up?" • Important question to ask parents when trying to ascertain quality + extent of patient's pain experience, especially for young children who may not be able to accurately describe or locate pain • Generally, persistent pain which wakes a patient or keeps a patient awake without obvious stimuli (food, sweets, cold or hot liquids) indicates irreversible pulpitis

Pulp Therapy for Young Permanent Teeth Young Permanent Teeth: • Open apex (≥ 1mm) - don't close for 3-4 YEARS after eruption of tooth • Thin dentinal walls • Short root • Dynamic developmental state • Pulp spaces: Larger -> Larger coronal pulp chambers + incomplete radicular portion Minimal Secondary Dentin -> weaker especially in peri-cervical area • Apical papilla: large #s of stem cells • Immature Apex: connection with apical papilla = robust with copious innervation + vasculature • Pulp tissue: Highly vascular, Less fibrous • Peri-cervical dentin (PCD) - dentin near alveolar crest, ~4mm coronal to + 4mm apical to crestal bone • No underlying tooth under

Distinct from primary + mature permanent teeth -> impact pulp therapy options + prognosis 1. Young permanent teeth -> in a dynamic developmental state • Assessment of their stage of development = essential for well-informed + appropriate diagnosis + treatment planning 2. Pulp spaces + consequently pulp tissue = larger in volume in young permanent teeth due to large coronal pulp chambers + incomplete development of radicular portion of tooth 3. There is minimal secondary dentin along walls of pulp space in young permanent teeth • This makes tooth structurally weaker, especially in peri-cervical area, than mature permanent tooth whose root walls = thicker due to deposition of secondary dentin 4. Incompletely formed roots in young permanent teeth = shorter + thus may have shorter working lengths than in mature permanent teeth 5. Apices of young permanent teeth DON'T close for 3-4 years after eruption of tooth • Apical papilla contains large #s of stem cells • When apex immature, connection with apical papilla = robust with copious innervation + vasculature 6. Pulp tissue in young permanent teeth = highly vascular 7. Pulp tissue in young permanent teeth = less fibrous than in mature permanent teeth 8. Peri-cervical dentin (PCD) - dentin near alveolar crest, ~4mm coronal to + 4mm apical to crestal bone • In endo treated permanent teeth this area crucial in transferring load from occlusal table to root • In regenerative procedures this area should be optimized developmentally + in traditional endodontically treated teeth this area should be reinforced using restorative materials • Without appropriate management of PCD prognosis of tooth = negatively affected in a significant way

Assessment of Traumatic Injuries More complex -> RATIONAL + SYSTEMATIC EXAM procedure essential in order to establish a complete + correct diagnosis of all soft + hard tissue injuries

Due to complexity of traumatic oral injuries a RATIONAL + SYSTEMATIC EXAM procedure essential in order to establish a complete + correct diagnosis of all soft + hard tissue injuries • Trauma forms = an excellent practice tools to use to record your findings as it will guide your exam in a more methodical way + will reduce chance of overlooking any potential traumatized tissues

2. Exam of Soft Tissues E. Extraoral swelling HOSPITALIZED IMMEDIATELY: Peri-orbital area or soft tissue below inferior border of mandible -> risk of space infection or fascial plane infection -> life- threatening condition • Treatment of dental issues -> secondary + patient should be referred to emergency room for IV antibiotics without delay Facial Swelling Danger Zones: • Peri-orbital Swelling • Swelling below inferior border of mandible

E. Extraoral swelling • Involves peri-orbital area or soft tissue below inferior border of mandible -> risk of a space infection or fascial plane infection + SHOULD BE HOSPITALIZED IMMEDIATELY -> life- threatening condition • Treatment of dental issues -> secondary + patient should be referred to emergency room for IV antibiotics without delay Facial Swelling Danger Zones: • Peri-orbital Swelling • Swelling below inferior border of mandible

PEDS CLINIC: MTA Pulpotomy for Primary Teeth Summary Diagram Image: GI cement -> GI - > MTA -> Vital Pulp Tissue • Primary seal: Condense MTA over root stumps (4-8 hour set) • Secondary seal: GI over MTA • Pulp chamber: GI cement • Restoration of choice: SSC

Equivalent success rates to formocresol pulpotomies + considered standard of practice Advantages (over formocresol): 1. Avoidance of use of a known carcinogen (formocresol), 2. Clinical outcomes equivalent to, or by some reports superior to, pulpotomies completed using formocresol. Steps: 4. Once hemostasis obtained, MTA mixed according to manufacturer's directions, + mix placed over pulp stumps, + gently condensed using a condenser or other hand instrument to firmly contact pulp stumps • Once MTA set (can take 4-8 hours) -> provides primary seal over pulp, however because of extended set time for MTA, secondary seal necessary to complete procedure in timely way 5. Unset MTA covered with GI material (GIBase) which provides essential secondary seal while MTA sets 6. Tooth can now be restored with a SSC, which restoration of choice for pulpotomized primary teeth

3. Pain F. Reversible Pulpitis Cause: Thermal, chemical or mechanical stimuli Elicited (eating, chewing) = Less severe Dentin exposure + transmission of stimuli through dentinal tubules + typically described as having a SHARP LANCINATING quality

F. Pain provoked by thermal, chemical or mechanical stimuli (such as hot/cold, sweet foods or beverages, chewing, etc.) + doesn't linger significantly often suggests a lower-level inflammatory reaction in pulp + can often be diagnosed as reversible pulpitis • This pain may also be attributed to dentin exposure + transmission of stimuli through dentinal tubules + typically described as having a sharp, lancinating quality • This type of pain suggests reversible pulpitis,+ if substantiated by other findings, vital pulp therapies should be considered.

6. Restoration of choice, for pulpectomized posterior primary teeth -> SSC

For pulpectomized primary anterior teeth: need for durability must be weighed against esthetic concerns, but an extracoronal restoration is definitely indicated, + if a strip (composite) crown chosen, parents should be made aware of its poor durability as an anterior restoration • For somewhat more esthetics than offered by an unaltered SSC, lab processed acrylic faced SSC or windowed SSCs can be considered

Non-Vital Pulp Therapy 1. Pulpectomy for Primary Teeth - Removal of coronal + radicular pulp tissue + obturation of these pulp spaces For: • If pulpal degeneration (irreversible pulpitis/pulpal necrosis) progressed to extent that pulp tissue in RADICULAR CANALs • Most commonly used to preserve primary 2ND molars pending eruption of adjacent permanent 1st molars How it works: • Conserves non-vital primary teeth by removing all necrotic tissue, instrumenting radicular canals, + filling them with ZOE or Vitapex • Extraction of non-vital primary teeth is another treatment option which should always be considered Summary Diagram Image: IRM -> ZOE paste • IRM = "Intermediate Restorative Material" = ZOE + hardener • ZOE = "Zinc Oxide & Eugenol" = more absorbable than IRM • Entire pulp (coronal & radicular) removed • SSC restoration of choice

For: • If pulpal degeneration (irreversible pulpitis/pulpal necrosis) has progressed to extent that pulp tissue in radicular canals is affected, then pulpectomy must be considered • Most commonly used to preserve primary second molars pending the eruption of adjacent permanent first molars How it works: • Conserves non-vital primary teeth by removing all necrotic tissue, instrumenting radicular canals, + filling them with ZOE or Vitapex • Extraction of non-vital primary teeth is another treatment option which should always be considered

Young Vital Permanent Teeth Pulpotomy Indications Vital pulp of immature permanent teeth Large pulp exposure when removing caries Aysmptomatic teeth No soft tissue involvement/radiographic pathology Trauma

For: Young vital permanent teeth with incompletely formed (immature) apices when: 1. Large pulpal exposure during removal of clinical caries in teeth with asymptomatic pulps 2. Tooth free from history of prolonged or spontaneous pain, no sensitivity to percussion, redness, swelling, mobility, bone loss or internal resorption. 3. Clinical + radiographic evidence suggests that peri-apical tissues healthy (i.e. no pathologic peri-apical radiolucency, no parulis or sinus tract) 4. Traumatic injury -> fracture of clinical crown with pulpal exposure • Patient should be seen within few hours post-accident

Medicaments + Other Materials Used in Pulpal Therapy 5. Formocresol • Bactericidal -> "sterilizes" interface with remaining vital pulpal tissue, but also causes some damage to that tissue -> transient inflammation in small zone immediately adjacent to area fixed by formocresol 2 major components: A. Formaldehyde • Application -> varying degrees of loss of pulp vitality • Acts by forming intra- + inter- molecular bridges between various groups of amino acids preventing autolysis of tissue (property termed "fixation") B. Cresol - cell-membrane disrupting + protein-denaturing agent that can be expected to cause necrosis

Has 2 major components: formaldehyde + cresol A. Formaldehyde • Formaldehyde application results in varying degrees of loss of pulp vitality • Formaldehyde acts by forming intra- + inter- molecular bridges between various groups of amino acids preventing autolysis of tissue (property termed "fixation") B. Cresol - cell-membrane disrupting + protein-denaturing agent that can be expected to cause necrosis Formocresol characteristics: • Bactericidal + thus "sterilizes" interface with remaining vital pulpal tissue, but also causes some damage to that tissue, resulting in transient inflammation in small zone immediately adjacent to area fixed by formocresol

Pulpotomy for Primary Teeth Indications Routinely used in VITAL primary teeth 1. Pulpal exposure when removing caries 2. History of solicited pain (NOT spontaneous pain) + Radiographic caries involving pulp 3. Mechanical exposure 4. No radiographic evidence of pathologic resorption

Indicated for VITAL primary teeth 1. Pulpal exposure incurred while removing all caries from a primary tooth 2. Primary tooth with history of solicited pain (NOT spontaneous pain) + radiographically demonstrating deep carious lesion may be a candidate if caries exposure found 3. Mechanical exposure in primary tooth. (Cautious use of direct pulp caps in primary dentition considered).

Pulpectomy in primary anterior teeth Pulpectomy Precautions: 1. WORKING LENGTH of primary anterior tooth may difficult to accurately measure because of difficulty of obtaining distortion-free anterior radiograph, yet overextension of file can potentially seed peri-apical area of tooth with infected material or damage underlying developing permanent incisor in young patients Solution: Approximating LENGTH OF ROOT in relationship to size of CLINICAL CROWN OF TOOTH (instead of measurement taken from a distorted radiograph) -> prevent over-extension 2. ZOE paste (absorbable) preferable not extruded beyond apex of tooth being treated -> gentle placement 3. In young patients, whose permanent incisors developing immediately adjacent to apices of primary anterior teeth, consequences of failed pulpal therapy or local trauma from pulp therapy procedure -> damage to developing permanent incisors -> Extractions considered

Indicated when these teeth have irreversible pulpitis or when practitioner elects this procedure over pulpotomy for reasons outlined previously in this section of course manual Pulpectomy Precautions: 1. Working length of primary anterior tooth may be difficult to accurately measure because of difficulty of obtaining a distortion-free anterior radiograph, yet overextension of file can potentially seed the peri-apical area of tooth with infected material or damage underlying developing permanent incisor in young patients • Approximating length of root in relationship to size of clinical crown of tooth (instead of a measurement taken from a distorted radiograph) is an approach which can help prevent over-extension 2. While ZOE paste used as a filler material in pulpectomy procedure is absorbable, it's preferable that paste not be extruded beyond apex of tooth being treated, thus gentle placement of that material important In young patients, whose permanent incisors developing immediately adjacent to apices of primary anterior teeth, consequences of failed pulpal therapy or local trauma from pulp therapy procedure can result in damage to developing permanent incisors • For this reason, extraction of compromised primary anterior teeth should always be considered as a treatment option

Diagnostic Parameters: Never rely on only 1 of them to establish your Dx -> Rely on COMBO of DX 1. Radiographic Exam A. Pathologic Bone Resorption • Because of large # of accessory canals extending from coronal portion of pulp chamber floor to furcation in primary molar tooth, this bony destruction is seen radiographically in furcation area of primary molar • Periapical bony destruction can be observed in single-rooted anterior primary teeth secondary to pulpal pathosis • When infection chronic + long-standing, bone resorption can become extensive, involving not only furcation but periradicular + periapical areas of primary molar as well • As bone in furcation area may not be particularly dense under normal circumstances it's always wise to check for a continuous perio membrane associated with tooth in question, + also to observe quality of bone of furcation area of the contra-lateral tooth for similarity or dissimilarity Dissimilarity suggests possibility of pathological process • Finding of bone resorption may be indicative of widespread pulpal necrosis + non-vitality of associated tooth • In primary teeth these findings, in combo with other corroborating findings, suggest that infectious process has extended outside of tooth which indicates non-vital pulp therapies or extraction • Note that pathologic bone resorption PATHOLOGIC BONE RESORPTION = typically seen peri-apically PERI-APICALLY in PRIMARY INCISORS + close proximity to developing permanent successors In immature permanent dentition particular caution should be observed in diagnosing periapical bone resorption due to physiologic radiolucency associated with apical papilla + incomplete apices of these developing teeth as compared to normal root development

Infection: bone -> destroyed • Because of large # of accessory canals extending from coronal portion of pulp chamber floor to furcation in primary molar tooth, this bony destruction is seen radiographically in furcation area of primary molar • Periapical bony destruction can be observed in single-rooted anterior primary teeth secondary to pulpal pathosis • When infection chronic + long-standing, bone resorption can become extensive, involving not only furcation but periradicular + periapical areas of primary molar as well • As bone in furcation area may not be particularly dense under normal circumstances it's always wise to check for a continuous perio membrane associated with tooth in question, + also to observe quality of bone of furcation area of the contra-lateral tooth for similarity or dissimilarity Dissimilarity suggests possibility of pathological process • Finding of bone resorption may be indicative of widespread pulpal necrosis + non-vitality of associated tooth • In primary teeth these findings, in combo with other corroborating findings, suggest that infectious process has extended outside of tooth which indicates non-vital pulp therapies or extraction • Note that pathologic bone resorption PATHOLOGIC BONE RESORPTION = typically seen peri-apically PERI-APICALLY in PRIMARY INCISORS + close proximity to developing permanent successors In immature permanent dentition particular caution should be observed in diagnosing periapical bone resorption due to physiologic radiolucency associated with apical papilla + incomplete apices of these developing teeth as compared to normal root development

Pulpotomy Technique for Primary Teeth 1. Access: #330 bur (laterally around periphery) • "Unroof" the chamber

Initial steps same for both MTA + formocresol pulpotomy • 2 techniques diverge in management of radicular pulp stumps IMPORTANT NOTE: Once pulp of tooth accessed, ONLY sterile water used for irrigation to reduce risk of systemic infection from water borne pathogens 1. Access pulp chamber at central pit area of tooth using #330 bur • Feel "drop" of bur as it enters pulp chamber • Care exercised to avoid perforating floor of chamber with bur • Once in pulp chamber, widen outline form to shape suggested by location of radicular canals for better access • Bur should be moved laterally around periphery of chamber to ensure that entire roof of chamber removed • Removal of roof in this manner provides complete access so that all coronal contents can be removed Knowledge of internal morphology of primary tooth being treated will allow an access opening shaped such that all radicular canals will be ultimately exposed with minimal overhanging tooth material

Formocresol vs. MTA Pulpotomy for Primary Teeth • In formocresol pulpotomy this tissue chemically cauterized • In MTA pulpotomy procedure, this tissue covered with an inert material (MTA)• Both procedures require vital radicular pulp tissue + to be successful both procedures maintain vitality of that radicular pulp tissue

MTA pulpotomies show comparable success rates to formocresol pulpotomies in primary teeth • Due to concerns around formocresol + improved availability + cost of MTA, the MTA pulpotomy may eventually become treatment of choice • Both cited as appropriate treatment in current AAPD guidelines • While goal of each variation of this pulpotomy procedure is same, primary difference lies in treatment of exposed radicular pulp tissue at orifices of canals • In formocresol pulpotomy this tissue chemically cauterized • In MTA pulpotomy procedure, this tissue covered with an inert material (MTA) • Both procedures require vital radicular pulp tissue + to be successful both procedures maintain vitality of that radicular pulp tissue

Managing Emergency Pulpal Problems Toothache + Swelling Emergency visit: relieve pain Considerations: 1. Determine extent (picture please) 2. Localized swelling: Antibiotics or schedule for treatment If antibiotics: Amoxicillin: 25-100 mg/kg/24 hr every 8 hrs (t.i.d) Azithromycin 10-12 mg/kg on day 1m 5-6/kg 1x daily for day 2-5 3. Analgesics - Acetaminophen or Ibuprofen preferred NO ASPIRIN for children 4. Determine treatment: pulp therapy or extraction

On occasion, practitioner must deal with acute exacerbation of pulpal inflammation that produces acute pain and/or swelling • When this occurs, usually indication of advanced degenerative changes in pulp + or surrounding tissues. • Management of these situations usually requires extraction or occasionally a pulpectomy procedure if short-term preservation of compromised tooth is desired for space maintenance purposes A child presenting with this problem usually complains of acute spontaneous pain • Swelling may or may not be present • If present, swelling may be intra-oral + limited to gingival tissues or more severe + extend extra-orally as in a cellulitis*

Evaluation of Pulp Therapy

Parent + patient should be instructed to be alert for any developing signs or symptoms of failure of any pulpal therapy rendered • Development of spontaneous pain, gingival swelling, a parulis, a sinus tract, or expression of exudate from gingival sulcus, may indicate treatment failure • Other signs of failure include mobility, sensitivity to percussion + lingering pain elicited by thermal stimuli • A treated tooth that is clinically asymptomatic may still be a failure, thus radiographic monitoring is important. Check teeth which have received pulp therapy radiographically 6 months to a year after pulp therapy has been completed, when radiographs might typically be taken at a recall visit If no clinical signs or symptoms of potential pulp therapy failure, as outlined above, only pulp therapy procedure for which a yearly radiographic evaluation indicated is for primary teeth which have been treated with pulpotomy, + that yearly exam can be accomplished with radiographs indicated for other purposes • Absent the need for any other radiograph which would allow visualization of pulpotomized primary tooth, a yearly radiograph can be taken expressly to evaluate pulpotomized tooth • Continue to clinically monitor teeth that have had pulpal therapy at recalls + other office visits

5. When filling canals, several methods may be employed.

Paste may be placed with help of root canal condensers, a Lentulo Spiral, pressure syringe (Pulpdent) or Eugoseal Syringe (Centrix)* • Canals of primary anterior teeth = large + little difficulty usually encountered in filling them with these techniques • Canal obturation in posterior primary teeth can be more difficult because of their irregular anatomy *If a syringe used to irrigate with sodium hypochlorite or to place ZOE, care must be taken to avoid wedging syringe in canal and/or excessive pressure, which will express either material from apex of tooth • Sodium hypochlorite = caustic + can cause tissue necrosis • While ZOE relatively absorbable, its presence in periapical tissues can be irritating + isn't desirable

Pulp Therapy Procedures for the Primary Dentition Primary Teeth Distinctions: 1. Resorb + replaced by permanent teeth • State of resorption + projected lifespan of tooth (dental developmental status) -> carefully assessed + factored into pulp therapy options 2. Pulp spaces have numerous small accessory or secondary canals which provide communication between pulp + PDL 3. Non-vital Pulp: Primary posterior teeth: Pathosis in FURCATION area -> from a non-vital pulp Primary anterior teeth: Periapical radiolucency 4. Pathosis -> damage underlying permanent teeth if those permanent teeth at developmentally sensitive stage 5. Pulpal pathosis + other insults -> Premature resorption of primary teeth

Primary Teeth • Distinct from both young + mature permanent teeth • Appropriate + successful pulp therapy in primary teeth must account for + accommodate these distinctions 1. Primary teeth resorb + ultimately replaced by permanent teeth • State of resorption + projected lifespan of tooth (dental developmental status) must be carefully assessed + factored into pulp therapy options 2. Primary tooth pulp spaces typically have numerous small accessory or secondary canals which provide communication between pulp + PDL 3. Primary posterior teeth tend to exhibit pathosis resulting from a non-vital pulp in furcation area, while evidence of a non-vital pulp is typically seen as periapical radiolucency in primary anterior teeth 4. Pathosis in either of these areas can damage underlying permanent teeth if those permanent teeth are at a developmentally sensitive stage 5. Pulpal pathosis + other insults can stimulate premature resorption of primary teeth

Pulpal Management: Procedure Summary - Primary vs. Young Permanent Teeth

Primary Teeth vs. Young Permanent Teeth: 1. Primary Teeth A. Vital Pulp Therapy: Indirect Pulp Cap: OK (GI) Direct Pulp Cap: NO for carious exposure OK for small mechanical or traumatic exposure when pulp is otherwise healthy (MTA/GI) Formocresol Pulpotomy: IRM/SSC MTA Pulpotomy: MTA/Gl/SSC Pulpotomy: See Formocresol Pulpotomy and MTA Pulpotomy above B. Nonvital Pulp Therapy: Pulpectomy: ZOEorVitapex/IRM / SSC Apexification: NO Pulpal Regeneration: NO 2. Young Permanent Teeth A. Vital Pulp Therapy: Indirect Pulp Cap: GI Direct Pulp Cap: MTA/GI Formocresol Pulpotomy: NO MTA Pulpotomy: see Pulpotomy (young permanent teeth) below Pulpotomy: MTA / GI B. Nonvital Pulp Therapy: Pulpectomy: NO Apexification: MTA/Gutta percha Pulpal Regeneration: Immature permanent teeth with open apices

Pulpotomy Challenges Primary Anterior Teeth: 1. Clean amputation of coronal pulp tissue difficult: Junction between coronal + radicular portions of pulp = indistinct Easier: Posterior primary teeth where chamber floor serves as clear landmark 2. Accurate clinical assessment of health of remaining radicular pulp tissue difficult: Small diameter of pulp at area of CEJ + small access opening 3. Permanent incisors developing immediately adjacent to apices of primary anterior teeth, consequences of failed pulpal therapy -> significant ABSCESS abscess -> damage to developing permanent incisors Why Pulpectomy Considered: • Minimizes risk of inaccurate clinical assessment of radicular pulp tissue + subsequent abscess formation • Con: devitalizes tooth Study: No significant success rate differences between 2 treatments in primary incisors *If a SSC to be accomplished at same appointment as pulpotomy, it's usually advantageous to prep for SSC before starting pulpotomy procedure • Crown can be fitted on prepared tooth during 5 minutes needed for fixation of radicular pulp stumps

Pulpotomy in vital primary anterior teeth can be accomplished but presents some challenges unique to these teeth, + those challenges can often negatively affect success rate of procedure Challenges: 1. Junction between coronal + radicular portions of pulp = indistinct, which makes clean amputation of coronal pulp tissue more difficult than in posterior primary teeth where chamber floor serves as a clear landmark 2. Relatively small diameter of pulp at area of CEJ, combined with typically small access opening, makes accurate clinical assessment of health of remaining radicular pulp tissue very difficult In young patients, whose permanent incisors developing immediately adjacent to apices of primary anterior teeth, consequences of failed pulpal therapy -> abscess can be significant, including damage to developing permanent incisors Because of difficulties outlined above, some practitioners elect to complete pulpectomies in primary anterior teeth requiring pulp therapy, even if those teeth = technically vital • This approach minimizes risk of inaccurate clinical assessment of radicular pulp tissue + subsequent abscess formation • Pulpectomy procedure does however devitalize primary anterior tooth being treated Study: Randomized clinical trials have shown no statistically significant success rate differences between the 2 treatments in primary incisors *If a SSC to be accomplished at same appointment as pulpotomy, it's usually advantageous to prep for SSC before starting pulpotomy procedure • Crown can be fitted on prepared tooth during 5 minutes needed for fixation of radicular pulp stumps

Pyogenic Infections Antibiotic Therapy:

Pyogenic infections best treated with Amoxicillin in conjunction with removal of necrotic pulpal tissue or tooth itself • Fever alone ISN'T an indication for use of antibiotics Antibiotic Therapy: 1. Amoxicillin A. Dosage: • Children < 12: 20-40 mg/kg/24 hr q 8h (t.i.d.) • Children >12 & adults: 250-500 mg q8h B. Supplied: • 125 or 250 mg/5ml elixir • 125 or 250 mg chewable tablets 2. Azithromycin (Used for children with Penicillin allergy or sensitivity) A. Dosage: • Children up to 16 years: 10-12 mg/kg on day 1 (single dose), followed by 5-6 mg/kg once daily for day 2 to 5 • Adults: 500mg on day 1 (single dose), followed by 250 mg daily as a single dose for days 2 to 5. B. Supplied: • 100 mg/5 ml or 200mg/5mL elixir • 250 or 500 mg tablets An analgesic, preferably acetaminophen may be necessary • Aspirin should be AVOIDED in children

Pulpectomy Contraindications Radiographic evidence of: PATHOLOGIC or ADVANCED PHYSIOLOGIC root resorption Radiographic evidence of: 1. Pathologic root resorption 2. Advanced physiologic root resorption Like Pulpotomy: 3. Unrestorable tooth 4. Patient Risk of bacteremia

Radiographic evidence of: 1. Pathologic root resorption 2. Advanced physiologic root resorption

Module: Management of Traumatic Injuries in Pediatric Patients General Info: Trauma to oral region occurs frequently -> 5% of all injuries 0-6 years: oral injuries ranked 2nd most common injury covering 18 % of all somatic injuries Of oral injuries, dental injuries = most frequent, followed by oral soft-tissue injuries Causes: 1. Falls 2. Motor vehicle accidents (MVA) 3. Fights + assaults 4. Organized sports 5. Child abuse

Trauma to oral region occurs frequently + comprises 5% of all injuries for which people seek treatment Preschool children: Head + facial non-oral injuries make up as much as 40%of all somatic injuries 0-6 years: oral injuries ranked 2nd most common injury covering 18 % of all somatic injuries Of oral injuries, dental injuries = most frequent, followed by oral soft-tissue injuries Study: 12-year review of literature reports that 25% of all school children experience dental trauma + 33% of adults have experienced trauma to permanent dentition, with majority of injuries occurring before 19 Most common injuries to permanent teeth occur secondary to falls, followed by traffic accidents, violence, + sports

Factors for Successful Pulp Regeneration

Recent research + clinical trials produced a technique for treatment of immature permanent teeth with necrotic pulpal tissue, which may eventually replace apexification technique + offer an improved prognosis for these teeth Factors for Successful Pulp Regeneration: 1. Open (immature) apex • Works best on teeth with > 1.0 mm apical opening; it's not successful with mature teeth (closed apices) 2. Uninfected pulp space • The infected, necrotic pulp = irrigated copiously with 1- 2.5% sodium hypochlorite to remove as much necrotic tissue as possible • Subsequently, the pulp space = disinfected with a tri-antibiotic, bi-antibiotic, or calcium hydroxide (CaOH) pastewhich left in canal for up to a month • CaOH paste = recently studied substitute for antibiotic paste • It works by disinfecting irrigated canal space via its high (alkaline) pH • It's more readily available + has a longer shelf life than antibiotic pastes, which must be obtained from a compounding pharmacy + mixed individually for each procedure 3. Attraction of stem cells + stimulation of stem cell differentiation to form new pulp-like tissue • This is accomplished by irrigating the disinfected pulp space with EDTA prior to stimulation of a blood clot in pulp space 4. Presence of a scaffold into which vital tissue can grow. • Bleeding = stimulated following antibiotic treatment, + resulting clot provides necessary scaffold for ingress + proliferation of stem cells from apical papilla (SCAP) 5. Coronal seal • MTA used over clot + subsequently covered with GI to provide an initial seal which prevents ingress of oral bacteria which could potentially re-infect pulp space Teeth which successfully treated with pulpal regeneration often regain vital responses + show continuous root formation

Pulpal Regeneration Technique 4. Seal tooth using GI or another durable temporary material (not composite resin) over a sterile cotton pellet, + have patient return in 1 month for evaluation Symptoms resolved -> re-access + remove paste with EDTA irrigation

Seal tooth using GI or another durable temporary material (not composite resin) over a sterile cotton pellet, + have patient return in 1 month for evaluation • Resolution of symptoms (resolution of sinus tract, absence of pain, radiographic evidence of beginning resolution of periapical lesion, etc.) suggests that bi-antibiotic or CaOH paste can be removed • If symptoms persist, determine radiographically if bi-antibiotic or CaOH paste is still present; if not, re-apply + re-seal tooth for 1 month, then re-evaluate.

Pulp Therapy for Immature Permanent Teeth

Young Permanent Dentition (apex ≥ 1 mm opening) 1. Reversible Pulpitis (Vital Pulp) • Apexogenesis*: • Indirect pulp cap (GI liner + restoration) • Direct Pulp cap (pin-point exposure, MTA) • Partial Pulpotomy* (2-3 mm pulp removed MTA) • Pulpotomy (Coronal pulp removed, MTA) 2. Irreversible Pulpitis (Non-vital Pulp) • Apexification (Apical barrier with MTA + RCT) • Pulpal Regeneration (Irrigation + Ab paste/scaffold + MTA) *Cvek Pulpotomy - A partial pulpotomy done for an Ellis Cl III fracture from trauma • Pulpotomy procedure = same as a partial pulpotomy, only terminology changes • Partial pulpotomy = term used when pulpotomy done due to a carious pulp exposure • Cvek pulpotomy when pulpotomy done due to pulp exposed from trauma *Apexogenesis - histological term used to describe continued physiologic development + formation of root's apex • Can be obtained by implementing appropriate vital pulp therapy to young, vital, permanent tooth

Terminology: Fistula/Fisulous tract vs. Sinus tract Fistula - communication between 2 enclosed body cavities + mouth isn't considered an enclosed body cavity -> ISN'T correct for oral conditions

• Accurate, professional terminology = important in all areas of healthcare • It's a reflection of your knowledge + abilities • A common mistake = use of term "fistula" or "fistulous tract" to describe sinus tract Fistula - communication between 2 enclosed body cavities + mouth isn't considered an enclosed body cavity, thus "fistula" or "fistulous tract: ISN'T correct for oral conditions

Medicaments + Other Materials Used in Pulpal Therapy 4. GI Materials • Adhesive characteristic -> ideal for sealing dentin • Releases fluoride -> gives material an anti-carious property • Fast-setting (self-curing if pure GI, light-cured if compomer) • Micro-mechanical attachment with composite resin • Basic form: GI materials somewhat soluble in oral fluids, + over prolonged periods of time, "wash-out" of restorations can be noted • Hybrid GI materials, which include resin components, = much less soluble in oral fluids, + retain their excellent seal to dentin • GI material placed over deep portions of moderate + deep carious lesions + over MTA, to prevent microleakage

• Adhesive characteristic of GI makes it ideal for sealing dentin • Releases fluoride -> gives material an anti-carious property • Fast-setting (self-curing if pure GI, light-cured if compomer), + when used with composite there's a micro-mechanical attachment between composite resin + the GI material • In its basic form, GI materials somewhat soluble in oral fluids, + over prolonged periods of time, "wash-out" of restorations can be noted • Hybrid GI materials, which include resin components, = much less soluble in oral fluids, + retain their excellent seal to dentin • GI material placed over deep portions of moderate + deep carious lesions + over MTA, to prevent microleakage

Vital Pulp Therapies: 3. Pulpotomy for Young Permanent Teeth - removal of infected coronal portion of pup in young permanent teeth to promote root formation + apical closure (apexogenesis) Goal: Obtain Apexogenesis (Completed root formation, thickeningof radicular walls) + continued vitality of pulp Summary Diagram Image: IRM or Restoration -> GI sealing over MTA -> MTA -> Vital Pulp Tissue • Incomplete root formation= incomplete apices • Only coronal pulp removed IRM = temporary restoration • NO FORMOCRESOL (like in PRIMARY) • RCT may be required in future

• Affected coronal pulp tissues extirpated • Some cases, if radicular pulp tissues affected, unhealthy portion may also be removed, leaving presumably vital tissue in apical portion of roots (partial pulpectomy) • Healthy pulp tissue in radicular canals covered with MTA* then sealed against ingress of bacteria + their byproducts to allow root apex to continue developing to maturity + permit radicular pulp to maintain its vitality * Mineral trioxide aggregate (MTA) has gained acceptance for use in lieu of calcium hydroxide because of its apparent biocompatibility • Bio ceramic materials = currently gaining acceptance in lieu of MTA, because they don't cause discoloration of treated tooth + seem to have similar biocompatibility • However, no long term outcomes with bioceramics like there are with MTA Although, after pulpotomy -> pulp may not remain healthy indefinitely, with a mature root tooth will have a better prognosis should it need traditional root canal therapy + subsequent restoration Goal of pulpotomy procedure: obtain apexogenesis - to allow apex to mature + dentin walls to thicken sufficiently to improve prognosis of tooth, even should root canal therapy become necessary in future • In some cases, traditional root canal therapy may be avoided indefinitely, but prognosis of tooth remains more guarded than for non-endo treated tooth

PERRLA Test: Pupils Equal Round Reactive to Light + Accommodation

• An eye exam done to check nervous system function • Failure to meet any of PERRLA criteria considered indicative of cranial nerve damage, compression of optic nerve, possible concussion, or CNS injury

5. Percussion -> Inflammation in perio membrane space Unreliable in PEDS

• Can be diagnostically useful in older children • Positive response can indicate presence of inflammation in perio membrane space • However, variable reliability of child's response makes this of little value as a diagnostic aid in young children

1. Radiographic Exam B. External Root Resorption • Commonly associated with pathologic bone resorption • Pathologic root resorption indicates presence of infection for a prolonged period, + generally precludes employment of any pulp therapy, instead suggesting need for extraction

• Commonly associated with pathologic bone resorption • Pathologic root resorption indicates presence of infection for a prolonged period, + generally precludes employment of any pulp therapy, instead suggesting need for extraction

Assessment of Traumatic Injuries 3. Consciousness Assessment

• Consciousness assessment - chance of concussion? HIGHEST PRIORITY • Problem signs present as physical, cognitive, emotional, + sleep symptoms Any of these findings: TRUE MEDICAL EMERGENCY -> CNS injury -> IMMEDIATE MEDICAL REFERRAL! • Loss of consciousness • Amnesia • Vomiting / nausea • Dizziness or loss of balance • Restlessness/ confusion • Change in personality • Unequal pupils

1. Radiographic Exam E. Radiographic proximity of compromised or lost tooth structure to pulp • Correlated with clinical findings + not just x-ray • If pulp exposed or compromised via lost/damaged tooth structure, pulpal therapy may be indicated

• Dental radiograph = 2D representation of the 3D tooth, thus care must be used in judging proximity solely based on a radiographic image • Proximity of compromised tooth structure or cavitation to pulp should be correlated with clinical findings • If pulp of tooth exposed or compromised via lost/damaged tooth structure, pulpal therapy may be indicated

3. Chamber flushed with STERILE WATER to loosen any debris + cleanse dentin • Free of tissue tags • No overhanging ledges • All canals have been exposed • No perforations 4. Bleeding controlled - pulp stumps will appear red, but shouldn't be actively bleeding ("Red Eye" stage achieved) Apply moist cotton pellet (sterile water) with pressure • Bleeding from radicular pulp stumps stop -> radicular pulp tissue healthy If bleeding persists: Irreversible pulpitis • Pulpal tissue remains in chamber or between radicular orifices • Radicular pulp = hyperemic (deteriorating) or Extract or pulpectomy

• Dry, sterile cotton pellet used to dry chamber + cotton pellet moistened with water then placed over stumps with moderate to firm pressure, for 1- 2 minutes to control bleeding from pulp stumps* When this has been accomplished, pellets removed, + chamber dried + examined to determine that: 1. Bleeding controlled - pulp stumps will appear red, but should not be actively bleeding ("Red Eye" stage achieved) 2. All overhanging ledges removed 3. No residual tissue tags remain 4. All pulpal canals exposed + clearly visualized 5. Floor of chamber hasn't been perforated *If bleeding can't be controlled with moist cotton pellets, -> distinct possibility that radicular pulp inflamed, signaling initiation of irreversible pulpitis -> alternate therapies: pulpectomy or extraction considered Procedure splits depending on medicament used

Formocresol Pulpotomy Formocresol: • Serves to "sterilize" area surrounding radicular pulp stumps, + to chemically cauterize those stumps to allow them to be sealed against ingress of bacteria or their byproducts • Causes complex vascular changes in pulp tissue, including a limited zone of inflammation • PURPOSE NOT TO STOP pulpal bleeding • Bleeding of radicular pulp stumps should be stopped in a vital pulp via DIRECT PRESSURE from a water-moistened cotton pellet prior to placement of formocresol

• In formocresol pulpotomy technique, formocresol serves to "sterilize" area surrounding radicular pulp stumps, + to chemically cauterize those stumps to allow them to be sealed against ingress of bacteria or their byproducts • Formocresol causes complex vascular changes in pulp tissue, including a limited zone of inflammation • Though common misconception, purpose of formocresol in pulpotomy procedure isn't to stop pulpal bleeding; bleeding of radicular pulp stumps should be stopped in a vital pulp via direct pressure from a water-moistened cotton pellet prior to placement of formocresol

Pulpectomy Technique for Primary Teeth Goal: • Retention of tooth until an adjacent permanent tooth erupts, or until pulpectomized primary tooth normally exfoliates • Prognosis: Poorer than pulpotomized primary tooth -> chances of survival until normal exfoliation significantly less than pulpotomized tooth Steps: 1. Access 2. All necrotic material removed from chamber + canals Careful not to push infected material through apices Irrigation: NaOCl 1-5%

• Involves complete removal of pulp tissue from non-vital primary tooth Goal: • Retention of the tooth until an adjacent permanent tooth erupts, or until pulpectomized primary tooth normally exfoliates • Prognosis for a pulpectomized primary tooth = poorer than for pulpotomized primary tooth, thus chances of its survival until normal exfoliation = significantly less than for a pulpotomized tooth Steps: 1. Access gained to pulp chamber as described for pulpotomy technique IMPORTANT NOTE: Once pulp of tooth accessed, ONLY STERILE WATER used for irrigation to reduce risk of systemic infection from water borne pathogens 2. All necrotic material should be removed from chamber + canals, being careful not to push infected material through apices • Canals irrigated thoroughly with dilute sodium hypochlorite* (or other disinfecting agent), rinsed with sterile water + dried • *1-5% concentration of sodium hypochlorite = appropriate for irrigation • Plain household bleach = ~5.25% sodium hypochlorite, so diluting it 1:1 with water, + then diluting resulting mix 1:1 again with water yields a solution that is ~1% sodium hypochlorite

Formocresol Pulpotomy for Primary Teeth • Involves use of known carcinogen: FORMALIN • High success rate, without evidence of ill effects • Success rate for MTA pulpotomy = equivalent Summary Diagram Image: IRM + Chemically Cauterized Pulp Tissue (Formocresol) + Vital Pulp Tissue • FC cauterizes root stumps • IRM over cauterized root stumps 6. 1 or 2 cotton pellets moistened (not saturated) with formocresol, + blotted dry in a gauze 2 x 2 -> condensed against pulpal stumps: 5 min -> remove • Avoid formocresol on gingival tissues -> caustic + will produce tissue necrosis • Count pellets to avoid leaving them in • Radicular pulp stumps: black ("Black-Eye" stage achieved), + no residual bleeding from pulp stumps -> successfully fixed by formocresol • Residual bleeding: radicular pulp inflamed (not healthy), + pulpectomy should be considered 7. IRM - dry mix -> more condensable IRM = ZOE + hardener = seals cauterized pulp stumps • Wet cotton tip applicator (Q-Tip) used with light pressure to smooth occlusal surface of IRM + to provide moisture to hasten set of IRM • Purpose of IRM: seal radicular pulp stumps; ISN'T intended or needed as core restoration in pulpotomized primary molar which is to receive a SSC • Amalgam condenser works well 8. Occlusion reduced slightly + IRM filling will act temporary restoration • More time -> final restoration with a SSC done too 9. Restoration of choice: SSC Why: Pulpotomized primary teeth become desiccated, + prone to coronal fracture

• Involves use of known carcinogen: FORMALIN • High success rate, without evidence of ill effects • Success rate for MTA pulpotomy = equivalent Steps: 6. 1 or 2 cotton pellets, large enough to cover only the floor of the pulp chamber, is/are moistened (not saturated) with formocresol, + blotted dry in a gauze 2 x 2. These dry formocresol pellets firmly condensed against amputated pulpal stumps (closed ends of cotton pliers work well for this) + left in place for 5 minutes* • A dry (no formocresol) cotton pellet can be placed over condensed formocresol pellets to keep them in intimate contact with pulp stumps during fixation period • Be careful that no formocresol allowed to seep onto gingival tissues, as it's very caustic + will produce tissue necrosis After 5 minutes has elapsed, cotton pellets should be carefully removed* so that radicular pulp stumps can be examined • They should appear black ("Black-Eye" stage achieved), + there should be no residual bleeding from pulp stumps • This indicates that pulp stumps have been successfully fixed by formocresol • If there residual bleeding noted, there's possibility that radicular pulp inflamed (not healthy), + pulpectomy should be considered • Alternately, if there's possibility that formocresol pellets weren't in intimate contact with root stumps, this portion of the procedure can be repeated *It's imperative that pellets not be left in coronal chamber of tooth, so counting pellets placed, followed by counting pellets removed, = advisable 7. Radicular pulp stumps now sealed with thick, dry* mix of IRM • Material placed + condensed** so that it's in intimate physical contact with amputated + fixed radicular pulp stumps • For convenience, chamber usually filled however only critical feature of IRM placement is that it completely covers amputated radicular pulp stumps, + provides complete seal • Following condensation of IRM, a wet cotton tip applicator (Q-Tip) can used with light pressure to smooth occlusal surface of IRM + to provide moisture to hasten set of IRM • Purpose of IRM = to seal radicular pulp stumps; it ISN'T intended or needed as core restoration in pulpotomized primary molar which is to receive a SSC *A dry mix of IRM more condensable -> works better in this application than wet mix ** An amalgam condenser works well for condensation of IRM® against chemically cauterized radicular pulp stumps 8. If only pulpotomy = to be done at visit, occlusion should be reduced slightly + IRM filling will act as temporary restoration • If time + patient's level of cooperation permits, a final restoration with a SSC can be accomplished at same visit 9. Restoration of choice for pulpotomized primary teeth -> SSC • As with endodontically treated permanent teeth, pulpotomized primary teeth become desiccated, + prone to coronal fracture • Use of SSC to restore these teeth prevents this problem

Treatment of acute pulpal problems should never be attempted with systemic antibiotics alone

• May be advisable to prescribe antibiotics, as outlined above, + re-appoint the patient for definitive treatment if extra oral swelling isn't present • This affords the highest probability of profound LA for definitive procedure If it's decided, for whatever reason, that preservation of tooth isn't desirable, extraction will be necessary • Extraction generally not recommended in presence of acute infection (extra oral or intra oral swelling)

4. Clean + dry canals with paper points 5. Obturation: ZOE paste or vitapex: Lentulo Spiral, Amalgam plugger, syringe (NOT IRM) IRM or GI can be used to seal coronal chamber over ZOE/vitapex paste in canal Restoration of choice: SSC/strip crown

• Once canals dry -> filled with a zinc oxide/eugenol (ZOE) paste or Vitapex • Note that IRM (zinc oxide/eugenol with a hardening agent) shouldn't be used, as this material will not absorb with physiologic resorption of tooth

*Peri-orbital or Submandibular Swelling - TRUE EMERGENCY

• Patient at significant risk of life-threatening facial plane infection + should be treated aggressively - extraction alone usually not adequate • Hospital admission for IV antibiotic treatment to control infection, evaluation for septicemia (blood culture) + extraction of causative tooth or teeth as soon as possible. • NEVER try to resolve this condition with a prescription for antibiotics to be taken at home - this patient needs emergency care in a hospital setting Facial Swelling Danger Zones: 1. Peri-orbital swelling 2. Swelling below the inferior border of the mandible Potentially Fatal Infection

1. Radiographic Exam C. Internal Root Resorption • Seen in radicular canals + again = evidence of advanced degenerative changes throughout pulp • Pulp therapy will generally not be successful as resorptive process ISN'T readily interrupted or slowed -> tooth has poor prognosis

• Probably be seen in radicular canals + again = evidence of advanced degenerative changes throughout pulp • Pulp therapy will generally not be successful as resorptive process ISN'T readily interrupted or slowed, thus tooth has poor prognosis

Once true emergency has been ruled out, initial decision dentist must make is whether or not to attempt to preserve tooth in arch

• Remember that early loss of a primary 1st molar usually brings fewer complications than loss of a primary 2nd molar • If it's advisable to preserve tooth but there is extensive swelling (especially cellulitis), pulp chamber may be opened + remaining pulp tissue or necrotic tissue removed • This will establish drainage of purulent material from pulp chamber • This isn't a definitive treatment; opened tooth will need to be extracted or pulpectomized at a later visit once swelling has resolved

4. Isolation for Pulpal Therapy Procedures MANDATORY: Rubber Dam (not others) + STERILE WATER for irrigation

• Scrupulous isolation of teeth receiving pulp therapy where pulpal tissue = exposed, even minimally, is of utmost importance • It's MANDATORY that rubber dam isolation be used whenever there is potential for contamination of pulpal tissue by saliva or other oral contaminants • Alternative isolation techniques (Isolite) cotton roll or dry angle isolation, DON'T provide adequate for isolation for pulp therapy procedures where pulpal tissue may be exposed to oral environment • Critical that ONLY STERILE WATER used for irrigation once pulpal tissue exposed Patient's treatment record should note isolation used + effectiveness of that isolation for pulp therapy procedures

1. Radiographic Exam D. Calcific masses or globules in pulp

• Such calcified bodies indicate chronic advanced pulpal degeneration with inflammation spread through coronal portion of pulp + into canals

7. Discoloration of Tooth ALONE -> NOT adequate diagnostically to consider pulp therapy A. YELLOW/BROWN: PULPAL CALCIFICATION -> rarely need for pulp therapy B. Gray/Red/Purple: Pulpal necrosis (breakdown of Hb)

• Teeth may discolor following trauma + nature of color change can provide valuable diagnostic info, especially in combo with other diagnostic parameters • Tooth discoloration alone ISN'T adequate diagnostically to consider pulp therapy, and distinguishing specific color may also be challenging A. Yellow/Light Brown discoloration: • Usually indicates pulp calcification, + rarely indicates a need for pulp therapy in absence of other symptoms B. Gray/Red/Purple discoloration • Usually indicates pulpal necrosis (some studies indicate that up to 80% of such teeth necrotic), + in conjunction with other positive findings can be an indication for pulpal therapy

4. Mobility Infection -> resorption (bone and/or tooth) -> mobility (late in cascade of event) Common: necrotic or extensively inflamed pulp -> mobility Differentiate between physiological + pathological mobility To see if extensive pathologic resorption of tooth or surrounding bone: compare with contralateral tooth + age

• Teeth with necrotic or extensively inflamed pulps often exhibit mobility • Mobility can also be related to degree of normal physiologic resorption of root; consequently, emphasis can't be placed on mobility alone as diagnostic tool • Together with radiographic evidence of change, a clinical finding of mobility maybe a valuable diagnostic criterion • If mobility suspected as result of extensive pathologic resorption of tooth or surrounding bone, comparison with contralateral tooth, as well as consideration of patient's general dental developmental age, can indicate whether tooth in question = demonstrating normal physiologic or abnormal pathologic mobility

2. Coronal pulpal tissue removed Tools: Slow speed: Large round bur* (# 4, 6 or 8) (preferred), or sharp spoon excavator • No pressure (risk of perforation , pull bur UP towards occlusal surface) • All residual tissue tags removed from floor + walls of chamber -> will continue to bleed + will make accurate evaluation of pulp stumps more difficult Trends: • Smaller burs increase chances of perforation of chamber floor + far less efficient • Pulling spoon superiorly, before radicular pulp tissue completely severed -> displacement + de-vitalization of radicular pulp tissue

• Use of bur preferred -> less chance of dislodging radicular pulp tissue than there is with spoon • Slow speed large round bur (# 4, 6 or 8) used for maceration of coronal pulp tissue + amputation of that tissue at orifices of radicular canals • Downward pressure shouldn't be applied to floor of chamber to avoid perforation + intro of dentin chips or debris into radicular pulpal tissue • Overhanging ledges can be removed with bur by pulling bur upward along chamber walls Trend: *Smaller burs increase chances of perforation of chamber floor + far less efficient than large bur is removing pulp tissue A. If spoon used to remove coronal pulp tissue -> should be placed firmly against floor of chamber, at opening of radicular canal • Pulpal tissue incised quickly by drawing cutting edge of spoon laterally to separate radicular pulp from coronal pulp tissue • Pulling spoon superiorly, before radicular pulp tissue completely severed, can cause displacement + de-vitalization of radicular pulp tissue Regardless of technique used in this stage, all residual tissue tags must be removed from floor + walls of chamber, as these will continue to bleed, + will make accurate evaluation of pulp stumps more difficult

1. Pulp Capping for Primary Teeth B. Direct Pulp Caps CONTRAINDICATED -> HIGH FAILURE RATE *may consider for minute mechanical exposures Study: When pinpoint mechanical (non-carious) exposure of pulp encountered during preparation or following trauma, + pulp in optimal health, direct pulp cap with biocompatible material such as MTA + restoration with a material that seals tooth from microleakage (GI), may be successful

• Usually NOT INDICATED IN PRIMARY TEETH WITH A CARIOUS PULP EXPOSURE because of high rate of failure • Failure of direct pulp cap -> presence of non-vital tooth requiring a pulpectomy or extraction • Alternative to direct cap for primary teeth, pulpotomy -> high clinical success rate, approaching 95%. Study: When pinpoint mechanical (non-carious) exposure of pulp encountered during preparation or following trauma, + pulp = judged to be in optimal health, a direct pulp cap with a biocompatible material such as MTA + restoration with a material that seals tooth from microleakage (glass ionomer), may be successful Our understanding of primary tooth pulpal response to direct pulp capping + prognosis associated with that procedure -> evolving • 2017 systematic review + meta-analysis of scientific literature on primary tooth vital pulp therapy suggested that highest level of success + best quality of evidence supported indirect pulp capping + primary tooth pulpotomy using MTA or formocresol Study: Direct pulp capping in primary teeth was shown to have similar success rate, but quality of evidence was lower. • This remains a robust area of scientific inquiry + better understanding + improved recommendations can be anticipated in future

3. Canals lightly instrumented with endo file Purpose: Reduce irregularities in canal walls + remove as much residual pulp tissue as possible • Stop filing ~2mm short of root apex • Primary molars: instrumentation to 30 or 40 endo file • Anterior teeth: larger file • Instrumentation progresses until lentulo spiral can freely go in + out of canal Goals of Instrumenting: A. Primary: IMPOSSIBLE to remove all bacteria due to many irregular canal configurations, interconnections + accessory canals • Uniformity of canal is of less concern, as canal will be obliterated with a paste (ZOE or Vitapex) rather than gutta percha • Both irrigating agent (sodium hypochlorite) + filling material (ZOE) are bactericidal + will eradicate what few bacteria remain in these areas after instrumentation • Vitapex = antibacterial + bacteriostatic B. Permanent: Remove all bacteria or to enlarge canal uniformly + shape it to receive gutta percha

• Utilizing radiographs, stop filing ~2mm short of root apex • Realize that in roots which are resorbing, apical canal opening may be coronal to most apical portion of root • In primary molars, instrumentation usually carried to a size 30 or 40 endodontic file • Instrumentation progresses until lentulo spiral (if using this method to obturate) can freely go in + out of canal • Anterior teeth will require instrumentation to a larger size file • Care should be taken not to force file past resistance point in canals (out the root apex) because of danger of introducing potentially infective debris into periapical tissues Goal of instrumenting canals of primary teeth ISN'T the same as that for permanent teeth • Permanent tooth: need to remove all bacteria or to enlarge canal uniformly + shape it to receive gutta percha. • Primary tooth: impossible to remove all bacteria due to many irregular canal configurations, interconnections + accessory canals • Uniformity of canal is of less concern, as canal will be obliterated with a paste (ZOE or Vitapex) rather than gutta percha • Both irrigating agent (sodium hypochlorite) + filling material (ZOE) are bactericidal + will eradicate what few bacteria remain in these areas after instrumentation • Vitapex = antibacterial + bacteriostatic

Assessment of Traumatic Injuries 2. Trauma History

• What happened? Witnessed by an adult? • Where? Contamination of wound or any fragments? • When? Time of injury + elapsed time until treatment sought • How? Impact zone? Type & direction of force? Rule out abuse: Suspicious of child abuse?

Orientation X3:

• Who are you? Where are you? What is today's date? • Valuable measure of patient's medical + neurological status • People who're able promptly + spontaneously to state their name, location, + date or time are said to be oriented to self, place, + time, or "oriented X3"

Medicaments + Other Materials Used in Pulpal Therapy 7. Sodium Hypochlorite • Endodontic irrigant in concentrations ranging from 1-5.25% to disinfect root canal system UOP: Use sodium hypochlorite in 1% solution • Oxidizing + hydrolyzing agent • Bactericidal + proteolytic • Damages all living tissues except KERATINIZED EPITHELIA • If expressed outside of radicular canal -> inflammatory reaction -> pain + localized or wide-spread swelling + bruise-like discoloration Study: While such reactions rare in children, can occur + precautionary measures warranted

• Widely used as endodontic irrigant in concentrations ranging from 1-5.25% to disinfect root canal system • We typically use sodium hypochlorite in a 1% solution • It's both an oxidizing + hydrolyzing agent + is both bactericidal + proteolytic • Sodium hypochlorite damages all living tissues except keratinized epithelia + must be handled carefully • If expressed outside of radicular canal, it can cause an inflammatory reaction, manifesting as pain + localized or wide-spread swelling + bruise-like discoloration Study: While such reactions are rare in children, they can occur + precautionary measures warranted