Dentin:

Wide dentinal tubuls;

Additional channels over the pulp horns;

Wide dentinal canals above the root delta;

Pulp:

Maturity level of pulp;

Size of the pulp chamber ;

Width of the root canals.

Degree of development of root canals:

Formation of root walls;

Formation of the apex;

physiological resorption:

Degree of root degradation;

Reactivity of the pulp;

Degree of development of the alveolar

bone.

pre eruptive

periodRoot construction Functional period Root resorption

4 yrs. 5 yrs

Inflammation is a localized protective

response that aims to remove the damaging

agents.

It occurs as a protective reaction against

foreign material that has invaded, most

often microorganisms.

There may be other causes, such as trauma,

toxins, chemical, and physical factors, but

most often, microorganisms are the main.

In the acute form, the classic five symptoms are observed: 1. pain (dolor),

2. fever (calor),

3. redness (rubor),

4. swelling (tumor,)

5. and impaired function (functio leasa).

A series of changes are beginning with the enlargement of arterioles, capillaries, and venules. The blood flow and vascular permeability increase; fluid and plasma protein exudation; migration of leukocytes to the site of inflammation begins. Leukocyte accumulation and activation are central to the pathogenesis of all types of inflammation.

Both forms of inflammation are the result of

activation of the humoral and cellular

responses of the immune system.

The immunological elimination of foreign

elements goes through several stages.

First, in order to be eliminated, any

material or antigen must be identified as

"foreign".

Identification may be specific or non-

specific.

It is done by immunoglobulins (antibodies) or through T-lymphocyte receptors that bind to specific sites (epitopes).

Non-specific forms of identification by which denatured proteins and endotoxins are detected are mediated by complement or by phagocytosis. The binding of the recognition components to the antigen leads to a deepening of the process, initiating the production of pro-inflammatory substances. These mediators alter blood flow, increase vascular permeability, enhance attachment of circulating leukocytes to the vascular endothelium, promote the migration of leukocytes into the tissue, and stimulate the degradation of invading agents.

Denatured proteins and endotoxins are detected

are mediated by complement or by phagocytosis.

The binding of the recognition components to

the antigen leads to a deepening of the process,

initiating the production of pro-inflammatory

substances.

These mediators alter blood flow, increase

vascular permeability, enhance attachment of

circulating leukocytes to the vascular

endothelium, promote the migration of

leukocytes into the tissue, and stimulate the

degradation of invading agents.

There are several reasons for a dental pulp

to become inflamed, but the far the

commonest is as a sequel to dental caries;

Dental caries in primary tooth progresses

rapidly to relatively thin enamel and

penetrates dentin;

The insult from bacterial toxins stimulates

the underlying pulp to respond by mounting

an inflammatory reaction – reversible

pulpitis.

The true immune mechanism for antigen

destruction is by phagocytes.

They can be freely moving or attached to

specific sites in the tissue as elements of the

mononuclear phagocytic system.

Macrophages and related cells, such as Kupffer

and synovial A cells, are central components of

this protection.

The degradation of the antigen outside the

mononuclear phagocytic system is related to

polymorphonuclear leukocytes (neutrophils) or

to monocytes coming from the circulating blood.

The pulp inflammation is influenced by the specificity of the causative agent and by the peculiarities of the pulp.

The pulp is connective tissue but has different anatomy, which determines the physiology and character of the emerging pathological processes.

Beyond these reasons, there is a specificity in childhood that further changes the nature of the reactions that occur, and this affects the whole process, the clinical picture, diagnosis, and treatment.

Primary teeth pass through their three developmental stages in just a few years – (1) embryonic, continuing until the end of root formation, an extremely short (2) functional period, and a prolonged (3) period of resorption.

During embryonic pulp development (two years after the eruption), the pulp is active and well protected both through all the young elements in it and the vitality of the growth zone.

- Another advantage is the short functional period, which does not allow the development of gradual changes with the loss of function of all its elements, as happens with the aged modified pulp of permanent teeth.

- During root resorption, the pulp is also active and well protected by the resorptive organ. It is highly vital, and, similar to the root formation, the wide apex ensures proper drainage of inflammatory products. That avoids the anatomical deficiency of the pulp location (the pulp is surrounded by solid mineralized dentin). At the same time, the resorption organ also provides protection through its young granulation tissue with an abundant blood supply.

The development of inflammation in the pulp

is completely different.

The pulp is closed inside the tooth and is

surrounded by dentin and enamel in the

crown.

In order to engage the pulp, an enamel and

then a dentine carious lesion must first

develop.

These lesions are the way to get the irritants

into the pulp.

Carious destruction of enamel and dentin is a chronic process.

It progresses with months and sometimes with years.

As the carious destruction approaches the pulp, the dentin permeability increases.

It creates an opportunity for the entry of ions and metabolic products released by the microorganisms into the carious defect. They cause a reaction from the pulp.

Recent studies have shown that when small doses of irritants enter the pulp chronically as a consequence of a developing carious lesion, slightly progressive chronic inflammation occurs in a small area.

It usually begins without the development of any prior acute response.

In an untreated dentinal carious lesion, bacterial products move along the dentinal tubules, which are wide and reach the pulp before microorganisms.

Antigenic bacterial products activate the immune response.

Due to the lower toxicity of the bacterial products, they cause activation of a cell-response, in which the macrophages play a significant role.

1) invading stimuli through the dentinal tubules;

2) odontoblasts;

3) neuropeptides and neurogenic irritation;

4) innate immune cells, such as immature

dendritic cells, natural killer cells, and T cells;

5) their cytokines and

6) chemokines.

Although the first two elements are not classic

components of innate immunity, they are the

unique elements that give specificity in

unlocking the pulp inflammatory response.

It is accompanied by the accumulation of lymphocytes, plasma cells, and macrophages - a characteristic feature of chronic stroke.

Inside the inflammatory infiltrate are immunocompetent cells corresponding to the carious lesion diffusing antigenic substances.

There is a proliferation of small blood vessels and fibroblasts that begin the production of collagen fibers.

The goal is to limit and isolate the inflammatory response and to maintain the underlying pulp.

This type of the pulp inflammatory response is known as a protective one.

It has been found that with a carious lesion

of 1 mm to the pulp, the inflammatory area

is insignificant.

With the reduction of preserved dentin to 0.5

mm, the inflammatory response progresses

and increases, but for a long time does not

cause exacerbation of inflammation.

This is the reason why it is possible to use

biological treatments for tissue repair.

It is the early involvement of the pulp in

inflammation while the great protection is

leading to chronification of the

inflammation, in which the pulp retains its

function.

Childhood creates favorable and unfavorable

conditions for the development of pulp.

a. Active tissue metabolism and protection.

b. Possibility to remove inflammatory

products, microbial toxins, and

microorganisms.

c. Opportunities to limit chronic

inflammation and preserve the function of

the remaining pulp.

d. Possibility of re-development of

inflammation leading to the recovery of the

affected tissue or true healing.

a. With the prevalence of inflammatory agents over the protection of the pulp tissue, the inflammation quickly passes from one phase to another, and the chronic inflammation rapidly exacerbates.

b. All the protective factors of the young pulp accelerate exacerbation and the progress of inflammation.

c. The lack of apex in the two teeth and root resorption during the temporary development of irreversible pulp inflammation leads to very rapid involvement of the periapical structures.

d. Irreversible pulp inflammation can only develop into periapical for hours.

e. In the case of irreversible pulp inflammation in teeth with incomplete root development and root resorption of the temporary tooth, it is impossible to apply routine endodontic methods of treatment.

Infection:

For deep cavities;

Secondary caries;

It is caused by:

microorganisms;

Microbial toxins;

Dentinal degradation products.

Microorganisms

Exo-and endotoxins

Degradation of odontoblastic processes

They are moving through dentine tubules

They are reaching to odontoblasts and nerve receptors

Is induced reflective Overcoming

reaction protection

Protection

When compensatory

mechanisms are running out

Inflammation

Exudation;

Alteration;

Proliferation.

Serous inflammation

Serum diapedesis

Plasma diapedesis

Pulp abscess

Cell diapedesis

Increase granular

cytoplasm

Relocation of nuclei

in dentine tubule

Disoriented odonto-blasts

Damage to the pulp-

dentin border

Destruction of the odonto-blasts

Depoly-merization

of the inter-

cellular space

Degradation of collagen fibers

Destruction of the vascular

walls

Develops chronic

ulcerative pulpitis

Chronic pulpitis

development of fibrosis

fibrous pulpitis

Growth of young granulation tissue

granulomatouspulpitis

Causing a massive increase in pulpal

response;

This is characterised by irreversible

inflmmation and tissue necrosis directly

adjacent to the site of exposure;

Bacteria and their products will progress

through the pulp tissue, resulting in

irreversible inflammation;

The response of pulpal and periodontal

tissues to such injury can lead to one of

several outcomes:

The periradicular tissues may affected

(periradicular periodontitis), with eventualy

involvement of associated tissue;

If the exposure site involves a large area,

Hyperplastic pulpitis (pulp polyp) may occur;

The tooth may be subject to pathological

resorption – for example, internal

inflammatory resorption.

A classification divides the pulp into two

groups - reversible and irreversible.

Depending on the symptoms, they are

divided into symptomatic and

asymptomatic.

Depending on the communication of the pulp

with the carious lesion, pulpitis is divided

into open and closed.

1. Reversible pulps:

a. Pulpitis asymptomatica clausa.

b. Pulpitis asymptomatica aperta.

2. Irreversible pulps:

a. Pulpitis symptomatica clausa.

b. Pulpitis symptomatica aperta.

History -unreliable; Clinical examination:

Visualexamination

Probe Percussion

Paraclinicalexami-nations

Depth of the carious destruction;

The color of carious dentin;

Communication with the pulp;

Smell of carious defect;

Redness of periapical mucosa;

Fistula.

Consistency of the carious

dentin;

Carious dentin

thickness;

Tooth motility.

Radiography (not at

pulpitis);

EPD (not at primary

dentition)

Child crying;

Waking up in the night;

Whether or not there a swelling;

Big carious defect

Emergency treatment on the same day

Transient pain

Long lasting pain

Presence of fistula

Urgency will appear at any moment.

Initially each pulp inflammation is a chronic process;

Practically there is no acute pulpitis;

There are exacerbation of existing chronic pulp inflammation;

The teeth pulp has good recreational opportunities.

Reversible pulpitis

Closed

Asymptomatic

Opened

Irreversible pulpitis

Closed Opened

Symptomatic

Pulp Therapy in the

Primary teethThe treatment plan should be based

on specific diagnosed findings,

medical status and the child's

behavior, social status of the family.

Reversible - closed asymptomatic pulpitis;

Large carious lesions without pulp symptom

"pain";

Pulp symptom "pain" is missing:

Spontaneous pain;

Night pain;

Provoked pain - over 1 min;

Occurrence of pain while eating or irritation

in carious lesions still does not mean pulp

symptom "pain".

Diagnosis of childhood pulpitis is performed

in several steps, the purpose of which is to

differentiate reversible from irreversible

stages of pulp inflammation.

It is necessary to identify the presence of

pulp communication and to take into account

the type of symptoms that reveal the

diagnosis.

The most crucial first step is to decide when

a carious lesion indicates that the pulp may

be involved in inflammation. It should be

done through a differential diagnosis

between caries, pulpitis, and pulp necrosis.

When sufficient suspicion for pulpitis is present,

the second step is to determine the nature of

the inflammation. Most important is the

differentiation of reversible stages of

inflammation. Only they can be treated to

preserve the vitality and function of the pulp.

They require special treatment. In irreversible

pulpitis, treatment possibility is significantly

limited and does not depend on the nature of

inflammatory exudation. In all cases, it is

sufficient to establish irreversibility, which

requires the complete removal of the pulp and

then the tooth restoration.

1. History of the disease.

2. Clinical signs and symptoms.

3. Thermal stimulation.

4. EPD diagnosis.

5. X-ray examination.

6. Modern diagnostic methods.

If the child comes for a prophylactic

examination, the anamnesis will not be

specifically targeted for the presence of

pulpitis but will be a standard data collection

for the individual's development, his or her

general medical and dental history.

The chronic pulpitis will only be passably

detected during the intraoral examination

when large carious lesions.

The main symptom of pulpitis is severe pain. The presence of pain allows distinguishing between symptomatic and asymptomatic pulpitis.

The presence of a symptom of "pain" is a clear sign of symptomatic pulpitis.

The name "asymptomatic pulpitis" does not mean that the signs of developing pulpitis are missing, but only the characteristic symptom of "pain" is missing.

The symptom pulp pain shows irreversible pulp inflammation. It occurs when there are so many irritants accumulated by the inflammation that the tissue with all its protective mechanisms cannot cope with. Then the nerve fibers are excited not by external stimuli form carious lesions during eating but by the pulp inflammation.

The first characteristic of irreversible pulpitis is spontaneous pain.

It occurs suddenly, has a sharp character, lasts differently depending on the duration of the process.

At this stage, the pulp protection is not completely destroyed, but only temporarily overcome.

In the initial stages of irreversible pulp inflammation, spontaneous pain is short and has long remissions.

The more the process progresses, the longer the pain becomes and the shorter the remissions are.

It is important to get information about the beginning of the pain and how long it has lasted.

When the pain occurs during sleep, it is a

sure sign of irreversible inflammation.

The question is whether the child woke up

crying of toothache, how this pain subsided,

or whether a painkiller was given to restore

the sleep.

We must be informed when occurred the first

awakening, how many times per night, how

long the attacks were.

It is difficult for the child to register the first

disease symptoms.

At the same time, even if it has been

recorded, it cannot characterize them and

then formulate them.

The parent is usually the main source of

information about the disease, especially in

pre-school children.

In infants, the only source is the parent.

All available data;

Existing complaints;

The general medical and dental history of

the child;

Complaint history at the moment.

Is there any evidence of pain;

Presence of spontaneous pain;

Presence of night pain;

The pain of cold, warm and sweet while

eating;

Pressure pain while eating;

Retention or duration of pain after irritation.

1. Do you feel anything when eating ice cream?

2. Do you feel something when you eat warm food, such as soup?

3. What happens when you eat something sweet, such as candy?

4. Do you sometimes wake up in the evening with a toothache?

5. Does this last long?

6. Does it hurt if you hit your tooth with a toothbrush or a fork or spoon?All available data on symptoms available should be verified and refined in the next study.

Before a clinical examination, we should

keep in mind the usual course of caries

development and its complications in

childhood:

- Carious lesions - usually in primary dentition

develop after the third year, in early childhood

caries after the first year;

- Pulpitis - in primary dentition - after the fourth

year, in early childhood caries - after the second

- Periapical inflammation - in a primary dentition

- after the fifth year, in early childhood caries -

after second years.

We perform a comprehensive examination to

determine extra- and intraoral status, and

targeted examination is performed only for

the teeth that arouse suspicion.

The dental status is established, but the

examination is directed to the jaw and the

side of the suspected tooth.

When a large dentine carious lesion is

detected in the dental status examination,

the corresponding tooth is subjected to a

basic examination to determine the

diagnosis.

In this process, a differential diagnosis

should be made between a carious lesion,

pulpitis, and periodontitis, as in all three

cases, a major carious lesion can be

identified at the first examination.

Cavitated or not cavitated.

Depending on location, lesions are occlusal,

approximal, and cervical.

- depth of the lesion;

- contours of the lesion;

- the hardness of carious dentin;

- affected cusps;

- pulp opening.

Every deep carious should be thoroughly examined.

In addition to its external dimensions, the lesion must be examined in depth.

The examination should be done through careful deliberation rather than deep probing (the probe should not be used to seek pulp communication).

The focus of the study is now on the diagnosis of reversible pulpitis, of which closed asymptomatic pulpitis is the most favorable for biological treatment.

Rough drilling seeking communication with the pulp is a rude mistake in the diagnostic process.

In order to determine whether the depth of the lesion corresponds to the affected pulp, some features of the children's teeth must be considered.

The first is that the depth of fissures in primary

molars is not great, since the enamel in this

tooth is the same thickness in all sections - 1

mm, and this reduces the risk of developing

occlusal caries compared to permanent teeth.

The dentin immediately below the fissure is

thicker, and this determines the longer course of

occlusal caries.

As a final result, in the study of occlusal caries in

primary teeth, relatively deep occlusal carious

lesions may be found that are not necessarily

related to the development of pulpitis.

The size of the approximal destruction

should be considered.

The contact between primary teeth is wide

rectangular, at all over the approximal

surface. A reason for it is the enamel swelling

in the cervix.

The enamel and dentin are thinner.

Thus, usually, the approximal lesions of the

primary teeth may not be deep at all, but at

the same time be dangerously close to the

pulp.

The superficially exposed pulp horns.

In primary teeth, such as the first lower primary molar, the pulp horn is 1.5 mm below the enamel surface.

In this case, an approximal carious lesion reaches the pulp horn extremely fast, and pulpitis develops.

In approximal lesions of the primary teeth, the depth is not the leading criterion, but the degree of involvement of the approximal wall.

When a shallow carious lesion but the entire approximal surface is covered, the most likely diagnosis could be pulpitis.

They are the rarest lesions in the primary

dentition.

The reason is the enamel, and the equally

thickness of 1 mm enamel layer even in this

area.

The lesion develops relatively slowly and

only in extremely aggressive environments

would be associated with pulpitis

The borders of the lesion are of utmost importance for the diagnosis of pulpitis;

In cavitated lesions, we should keep in mind that the dentin lesion is sometimes significantly wider than the observed cavitation.

We should look for a change in the enamel color at the periphery, which will be much better suited to the actual size of the lesion.

We are looking for the proximity of the carious lesion to the pulp horns, located just below the tip of the cusp.

We have to measure the distance between

the borders and the tip of the closest cusp.

If the borders are close to 1/2 of the

distance between the deepest point of the

fissure and the tip of the cusp, the pulp may

have been affected.

When caries dentin is removing, this must be

done with special care to avoid an incorrect

and unnecessary pulp opening.

If the lesion occupies most of this distance,

we can be sure that it is pulpitis.

We have to measure the distance from the

end of the lesion to the tip of the closest

cusp, and if it is equal to or more than half,

the most likely diagnosis is pulpitis.

The discoloration of the caries affected dentine

varies depending on the deposited pigments

from the breakdown of the affected structures.

The speed of development of the carious lesion

determines the degree of these pigments.

The faster a carious lesion develops, the fewer

pigments are deposited and usually, the color is

yellow to light brown.

In the chronic process, the more pigments are

deposited, and the color is dark brown to black.

The darker the carious dentin, the less the

possibility of pulp engaging is present.

The hardness of carious dentin is also an

indirect sign of eventual involvement of the

pulp, as it is crucial for the rate of

progression of carious destruction.

Soft consistency is a fast-paced process that

is more likely to develop pulpitis.

The solid texture speaks of a slow process

that is conducive to activating the protection

of the pulp-dentin complex and is more likely

to be caries.

When the carious lesion is so large that even

one of the molar cusps is destroyed, pulpitis

is the most likely diagnosis.

It is done with the help of a mirror and using air drying. It makes visible pulp opening.

The presence of ulcers is sought. Probing is not recommended because it is not necessary to establish disclosure.

If disclosure is present, probing is contraindicated. Such probing would be painful and would also disrupt the fibrous barrier in the pulp around the chronically developing ulcer. It stimulates the spread of the infection, which would ruin biological treatment.

If the pulp is detected and spontaneous or night pain is missing, the diagnosis is pulpitis asymptomatica aperta.

If no finding is made, the study continues to establish the differential diagnosis between caries and pulpitis asymptomatica clausa.

The application of agents with different

temperatures to the teeth stimulates pulp

sensory responses.

It is not applicable in primary dentition.

Large cavitated carious

lesions with:

1.Soften lighter or darker

carious dentin;

2. Lack of disclosure of the pulp

(pulpitis closed);

3. Cavitation affects closest

cusp;

4. The reserved portion is less

than ½ of the distance between

the tip of the cusp fissure.

Carious process covered the much of the occlusalsurfaces;

There is no disclosure of the pulp.

But staining of the enamel is in the vicinity of the tip of the nearest cusps;

Incolored dentin is below ½ of the distance between the bottom of the fissure and the tip of the cusp - closed pulpitis;

The size and location of cavitationcorrespond of pulpitis;

Absent disclosure;

Large carious

lesions with the

disclosure of the

pulp amongst

carious dentin;

Open pulpitis.

Absence of pain symptoms:

• Absence of night pain;

• Absence of spontaneous pain;

Permissible pain symptoms

• pain of cold, sweet and pressure at meals that disappear after removing the challenge;

Carious lesion is close to the pulp, a thin and

partially demineralized dentin over the pulp

horn.

Not be taken due to the subjective reaction of small children.

When it comes to tooth caries, you may remove the entire carious dentin over the pulp, even in the area of pulp horn without disclosing the pulp;

Over the pulp horn or at the bottom remains thin, sometimes colored, but durable and well mineralized dentin.

Clinical findings

Large carious lesions

with or without a disclosure of

the pulp;

Large filling with or without

a defects.

Spontaneous pain;

Nighttime pain;

Pain when chewing or at sweet and cold that does not pass immediately after elimination of the stimulus;

Need to give an analgesic;

Partially or

completely

demineralized

dentin over the

pulp;

Absence of dentin

over the pulp

horn.

There are quite rare;

Treating caries should significantly reduce pilpitis;

Correct treatment of reversible pulpitis should remove them.

Is subject to the biological principle and the minimally invasive approach.

1. Biological principle - minimum removal of the affected tissue or structure and maximum storage of the pulp tissue.

2. Minimally invasive approach - minimally invasive diagnostics, minimally invasive pain management, micro-invasive cavity preparation, minimally invasive carious dentin removed, minimally invasive pulp, and growth zone attitudes in both dentitions.

These principles provide significantly greater preservation of the oral health of adolescents, as well as of their mental and physical well-being.

of "National Association of

Pediatric Dentistry" for the

pulp treatment of primary

teeth

Treatment of reversible pulp inflammation

The most appropriate

method - indirect pulp

capping!

1. Provides treatment of the majority of all primary teeth pulpitis.

2. The easiest;

3. Most atraumatic;

4. The best accepted of children;

5. No anesthesia is required;

6. Provides proven results;

7. Saves the vitality of the tooth;

8. Saves the functionality of the dentition;

9. Ensures correct physiological change.

Argument for the effectiveness of indirect

coverage

First visit

It is the most common reversible pulpitis in primary dentition. The appropriate treatment method is indirect pulp capping. It is a biological and less traumatic operative method.The purpose of the indirect pulp capping is to heal pulp inflammation and preserve the pulp vitality.

It is achieved by:

- stopping the carious spread;

- influencing inflammatory changes in the pulp;

- stimulation of reactive dentin deposition;

- stimulation of remineralization in the over-pulpal dentin.

It can be realized in more than two visits.

While in the caries treatment, the affected

dentin can be safe, in indirect pulp capping,

some of the infected can left behind.

This dentin cannot be permanently retained

but can be used to affect the pulp.

Therefore, it is saving to avoid pulp

disclosure.

Can be used to distinguish healthy from

infected and affected dentin.

It shows the extent of dentin involvement

with discoloration.

The caries detector turns green if the dentin

is healthy. In the case of a thin layer of

demineralized/affected dentine, the caries

detector shows a pale red color. When the

dentin is infected, the caries detector glows

in deep red (Kabakchieva, Milcheva, 2016).

It provides a step-by-step, providing minimally traumatic action for children and the ability to administer even to young and restless children.

The infected dentin is removing gradually while providing sufficient time for the remineralization of part of the infected dentin.

During this time, new protective dentin is also deposited, which provides pulp stability.

When using the caries detector, the color is also changed -it turns pale red.

This means that the underlying dentin is mineralized and allows the treatment completion in the same visit. In some fields have red staining, indicating infected dentin

In these cases, we can repeat the procedure with calcium hydroxide capping to further remineralization and time to thicken the protective newly formed dentin.

First step:

Diagnosis – closed asimptomatic pulpitis;

• The clinical features shows softened carious dentin without exposing the pulp;

• Symptom-free tooth – no “pain symptom” .

1. comprehensive medical history;

2. review of past and present dental history and treatment,

including current symptoms and chief complaint;

3. subjective evaluation of the area associated with the

current symptoms/chief complaint by questioning the

child and parent on the location, intensity, duration,

stimulus, relief, and spontaneity;

4. objective extraoral examination as well as examination

of the intraoral soft and hard tissues;

5. if obtainable, radiograph(s) to diagnose pulpitis or ne-

crosis showing the involved tooth, furcation, periapical

area, and the surrounding bone; and

6. clinical tests such as palpation, percussion, and

mobility

All caries is first cleared from the cavity

margins with a steel round bur running at a

slow speed:

From the cavity margins;

In gingival basis for interproximal defect (maybe

with excavators);

Dentin in the area under the enamel-dentine

border should be healthy, well-mineralized;

Enamel-dentin border must be clearly visible.

1.Gentle excavation than follows on the pulpal floor, removing as much of the softened dentine as possible without exposing the pulp.

2. A thin layer of setting calcium hydroxide is then placed on the cavity floor to destroy any remaining microorganisms and to promote the deposition of reparative secondary dentine;

3. The indirect pulp cap was covered with zinc oxide-eugenolcement for 6-8 weeks;

4. Radiograph observation.

First step:

Radiographic review;

Observe dentin over the pulp - compared to the

first X-ray;

Expected results:

remineralization of demineralized dentin

and formation of new secundary dentin;

The cavity was re-entered to remove all remaining softened dentine;

Periodic clinical and radiographic review is then undertaken to monitor the pulp response

This method is not recommended for

exposed pulp due to caries of primary teeth

from AAPD (2001, 2004, 2009).

Not recommended by the British and IAPD.

Therefore now this method is not

recommended for the treatment of primary

teeth.

Recommended method –

pulpotomiy

To preserve the vitality of the radicular pulp - in primary teeth is difficult to apply and is not currently recommended by any major worldwide organization of pediatric dentistry;

To stimulate tissue regeneration and healing at the site of the of amputation - in primary teeth practically difficult to apply and is not recommended;

To become root pulp in inert mass - real purpose of the primary teeth and this is the easiest method.

Local analgesia;

Apply ruber dam wherever possible;

Remove caries and roof of the pulp chamber, remove coronal pulp;

Apply medicament to radicular pulp on a cotton pledget;

Remove the cotton pledget and check that there is no exessive haemorrhage from the remaining pulpal tissue

15,5% Ferric sulfate - cotton pledget with

medicament placed over the radicular pulp

for 15 sec

20% (1:5 solution) Formocresol (Buckly) for 5

min;

МТА;

Calcium hydroxid;

Acting on the surface of the radicular pulp;

Agglutinate blood proteins and stop bleeding;

It is suitable alternative to formocresol.

The oldest method with the worst results;

In recent years revived but the alternative to success is extraction of the tooth (fully eligible by the IAPD);

Traditionally been used;

There hav been some conserns about its toxivity, both locally and systemically;

It is used a 1:5 concentration Backlyformocresol solution;

It is hold 5 min in pulp chamber (1 min);

Zinc oxid eugenol;

Restore the crown, usually. With a stainless-steel crown.

Equal parts formaldehyde and cresol;

Concentration 1:5 is achieved when:

Three parts of glycerin;

One part of distilled water;

Mix in advance;

These four equal parts were mixed with one part

of the solution to Buckley.

Often results in extraction;

Glutaraldehyde: Formaldehyde is a small molecule, a

glutaraldehyde - large;

Formaldehyde requires a long time for fixation of the tissue - Glutaraldehyde act immediately.

The reaction of the glutaraldehyde can not be reversed.

Can be an alternative for treatment.

Encouraging results;

Require monitoring and evidence in primary teeth;

Require adapted technique;

Requires the cooperation of the child and the parents;

Bad results in primary teeth;

Require monitoring and evidence in primary teeth;

Require adapted technics and cooperation of the child and the parents;

Alternative - extraction of the tooth.

Mortal pulpotomy

Age of the children is not suitable for channel instruments;

The roots are in resorption;

Risk for permanent tooth bud;

The method is easy to use;

With sufficient reliability till time of physiological tooth change.

Desensibilisatio pulpae

Preparatio cavi dentis

Amputatio pulpae

Desinfectio pulpae

Mumificatio

Obturatio

There are two methods:

1. Method of Stransky – 3 visits;

2. 2. Formalin-resorcin method – 2 visits.

First visit: Diagnosis;

Caries removal In order to protect the child from the pain does not

remove the entire caries, but only the one that:

gives access to the pulp;

is a gingival margin (in second class cavity).

Devitalization of teeth by arsenic trioxide

Remove devitalized arsenic trioxide;

Cavity is formed, creating retention;

All caries removal;

Amputatio pulpae;

Desinfectio pulpae;

Mumificatio pulpae.

Caries removal from

cavity margins;

Last caries removal is

from pulp roof.

When the bur passes through the roof of the chamber a “dip” is felt;

Once this is felt the bur is not taken any deeper but moved sideways to remove the roof of the pulp chamber.

Remove coronal pulp

with a large round bur

or large excavators;

Escavators are safer

to avoid perforation

in the furcation

region.

With small round bur is removed the pulp from the root in 1-2 mm.

Liquid-A

Rp/

Tricresoli 20.0

Formalini 60,0

M.D.S./A/

Liquid - B

Rp/

Resorcini 40,0

Aq.destil. 50.0

M.D.S. /B/

Liquid –С

Rp/

Natrii caustici

Kalii caustici 4,0

Aq.dest.

24,0

M.D.S./C/

Mix a paste of:

ZnO

eugenol

thymol

Dense texture-

cover with

powder Zno

Place the equal

drops of liquid A

and B close to

each other. Mix

at the time of

placing in the

pulp cavity

Apart from

them, on the

same plate is

placed a drop

of liquid C.

Dip the cotton

pledget in

mixed liquids A

and B and

place it in pulp

cavity for 1min.

Dried cotton

pledget with

liquid Сput in

pulp chamber

for a second.

Fill the

periphery of the

root canals and

all pulp

chamber with

zinc oxid

eugenol and

thymol cement

for a provisional

filling.

Check for

complications.

If no – the

treatment

continues.

From zinc oxide

thimol cement

is forming a

room for filling.

Restoration.

Trikresol-formalin :

Lipid-soluble compound with the ability to cross

biological membranes;

Can to precipitate microbial cellproteins ;

Violates the lipid metabolism;

There are hydrophilic and hydrophobic groups.

Has antiseptic activity;

Anti-inflammatory activity;

The result of mixing trikresol-formalin-resorcin is a

bakelite;

Potassium sodium hydroxide catalyzed process.

Formation of bakelite became in 2 hours.

Before the formation of bakelite started separating paraformaldehyde: disinfecting;

bactericidal;

dehydrates;

coagulate the protein;

mummification;

Impacting.

Antiseptic:

Precipitated proteins of microbial cell;

Inhibits enzymes in microorganisms;

Dehydrates.

Eugenol - clove oil;

Thymol - oil of thyme herb;

Include:

Phenols and aldehydes;

biologically active substances;

Action:

Antiseptic;

Antiinflammatory;

Local anesthetic effect.

First visite – devitalisation.

Second visit: Caries removal;

Cavity preparation;

Pulp chamber roof removing;

Coronal pulp removing;

Radicular pulp (1-2 mm) removing

Of the sterile

plate is placed

a drop of 40%

formalin and

the tip of the

spatula with

resorcinol

crystal -

supersaturated

solution.

Dip the cotton

pledget and

place it in pulp

cavity for 2-5

min. With the

remaining

amount of the

solution and

zinc oxide stir a

hard paste.

Fill periphery of

the canals and

the base of the

pulp chamber,

with hard zinc-

oxide cement

all pulp cavity,

then -

restoration

Formalin - 40%

Denature the proteins in MO;

Bactericidal action;

Virucidal;

Sporicidal;

Poorly penetrates deeply.

Affect microorganisms and toxic degradation;

Not interfere with the healing process in periodontal and alveolar bone;

Antibacterial action to:

Str.haemolyticus

Str.Aureus

Bactericidal action:

Tricresol formalin - 51% sterility

Resorcin-formalin - 67% sterility