Study material

Date: 2015-10-07; view: 861.

Aims. To master the methods of devital amputation and devital extirpation at treatment of pulpitis of permanent teeth in children.

Among the existing methods of pulpitis treatment in children biological and vital methods are the most preferred. But there exist some difficulties, in some cases- contraindications for the local anesthesia administration , which are the cause of the fact that devital methods are widely used at pulpitis treatment in children.

Topicality.

Treatment of pulpitis of the permanent teeth in children. Devital methods. Indications. Methodics of implementation. Prognosis.

Control questions.

1. Define, name the indications and describe the methodics of vital extirpation in the permanent teeth in children.

2. What is apexogenesis? What conditions are required for its implementation?

3. What hydroxide-calcium-containing medications for the direct pulp covering do you know? What is the mechanism of their action?

4. Name the indications and describe the methodics of vital pulp extirpation; what are the peculiarities of sealing of the root canals after the pulp extirpation in immature tooth?

5. What are the criteria of pulpitis treatment effectiveness using the method of vital amputation and pulp extirpation in permanent teeth in children?

Devital amputation - is a method of treatment of pulpitis which stipulates for partial extraction of pulp( crown part) after its previous devitalisation and mummification of the root pulp.

This method is applied at treatment of some forms of pulpitis in the permanent teeth with immature roots. In such cases endogenic intervention is undesirable, because there exists a threat of traumatizing and infection of the periapical tissues, impairment of the growth zone, which may negatively influence onto the processes of formation of the permanent tooth root.

Indications for the devital amputation in the permanent teeth:

Only in teeth with immature roots these are: chronic fibrous pulpitis, chronic hypertrophic pulpitis, acute diffuse pulpitis.

In teeth with immature roots, if the conservative methods of treatment have proven to be ineffective or contraindicated, these are: hyperemia of the pulp, acute local pulpitis, acute traumatic pulpitis.

Methods of treatment. Devital amputation in the permanent teeth is performed through 2-3 dental visits.

The first visit– includes application of devitalizing paste.

The operations to be performed are: partial necrotomy; opening of the pulp horn; application of devitalizing paste; application of the hermetic bandage to provide the reliable fixation of this paste for the required period. In permanent teeth with immature roots only paraformaldehyde paste may be used for the pulp devitalization: Parapasta (Chema, Роlfa ), Depulpin (VОСО ), Devipulp та інші.

Mechanism of action of paraformaldehyde paste: pulp necrosis is a consequence of reaction of formaldehyde with aminogroups of the cellular proteins, which causes their denaturation. Paraformaldehyde also has dehydrating effect onto the pulp, which leads to its drying- mummification. The advantage of paraformaldehyde is also its antimicrobial action, the mechanism of which is just the same as onto the pulp cells. Paraformaldehyde paste is applied onto the permanent tooth for 10-14 days.

The second visit includes amputation of the crown pulp and covering the root pulp with antiseptic and mummificating paste. To perform this, the bandage is removed, the cavity of the permanent tooth is opened (considering its topography) as well as amputation of the crown pulp. After the pulp amputation we apply the paste with expressed antiseptic and dehydrating properties onto the root pulp. This will provide for preservation of the devitalized, mummificated pulp in the root canals for the required period. For this we use pastes with formalin, paraformaldehyde (as an antiseptic), creosol, and others. To cover the root pulp we may use zinc-eugenol paste with antiseptics (thymol, iodiform). A thin layer of paste is applied onto the floor of the tooth cavity and orifices of the root canals, it is thickened with the cotton swab.

The third visit – is changing a temporary filling onto the permanent one, if a temporary filling was applied during the second visit.

A methods of devital amputation (about 85%) has complications of chronic periodontitis. This is why after the devital amputation in the permanent tooth with immature root a child must stay under dental supervision before completion of the root apexification process, which may be determined clinically and roentgenologically. After this we should perform the endodontic treatment- instrumental and medicamental processing of the root canals and their sealing with an appropriate sealing material.

Devital extirpation– is a method of pulpitis treatment which stipulates for the absolute extraction of the pulp after its previous devitalization.

Indications for the devital extirpation in the permanent teeth:

In permanent teeth with mature roots: acute serous diffuse pulpitis, acute purulent pulpitis, pulpitis, complicated with periodontitis, chronic fibrous pulpitis, chronic hypertrophic pulpitis, chronic gangrenous pulpitis. If the conservative method of treatment has proven to be ineffective or contraindicated: hyperemia of the pulp, acute local pulpitis, acute traumatic pulpitis.

In permanent teeth with immature roots: acute purulent pulpitis, chronic gangrenous pulpitis, pulpitis with clinical or roetgenological signs of affection of periodontium. Methods of devital extirpation is performed for 2-3 visits.

The first visit– includes partial preparation of the carious caity, opening the pulp horn ad application of devitalizing paste.

At treatment of the permanent teeth with mature roots, we may use arsenic paste for devitalization of the pulp.

Mechanism of action of the arsenic paste : necrosis of the cellular elements of the pulp proceeds as a consequence of action of Аs2ОЗ onto the oxidative enzymes, blockade of thyol -SН- groups and impairment of the metabolic processes.

Application of the arsenic paste in permanent teeth with immature roots is a gross mistake, because it always results in the toxical periodontitis development, death of the growth area and termination of the root formation. This is why it is necessary to keep to the rules when applying the arsenic paste.

The second visit includes removal of the bandage, opening the cavity of the permanent tooth considering its topography, and extirpation of the pulp from the root canals. While performing the devital extirpation in the permanent teeth with immature roots before initiating the treatment it is necessary to perform the roentgenography of the tooth to detect the degree of formation of the root and the working length of the tooth. After removal of the pulp the root canals of the permanent tooth must be sealed immediately. The choice of sealing material for the root canals depends on the degree of maturation of the root and group dependence of the tooth. In mature permanent teeth to seal the root canals we use gutta-percha pins with hardening sealers, sealing of the root canal is performed by the lateral gutta-percha condensation method. To seal the permanent mature molars we may use resorcin-formalin paste, prepared ех tempore, or the materials on its basis: Foredent (Spofa Dental), Endoform (Chema Polfa), Forfenan (Septodont), Resoplast and others. In every case, the quality of sealing of the root canals in a permanent tooth of a child must be controlled roentgenologically.

The criteria of quality of sealing of the root canals: equal density of material along the root canal, impermeability of filling, optimum degree of filling.

After devital extirpation the root canal must be sealed within physiological apex, by the level of the cement-dentin-canal junction. It is situated 1-1.5 mm lower than the root apex.

Insufficient filling of the root canal after the devital extirpation in permanent teeth of children always( 100% of cases) causes chronic periodontitis.