THE PULP I

PULP TREATMENTS IN PRIMARY DENTITION

 ORIGIN OF THE PULP
It comes from the dental papilla.

Its origin is the ectomesenchyma

 THE PULP
It may be divided in two different areas:

- Cameral pulp

- Radicular pulp
Histology of the pulp
 Histology of THE PULP
It is formed by a lax connective tissue covered by dentine.

We may find:

Fibroblasts and defensive cells (macrophages, eosinophils...)

Odontoblasts

Intercellular substance

Fibers

Ectomesenchymal cells
 Histology of THE PULP
dentin
There are 4 different areas:

- Odontoblastic zone in the periphery

- Cell-free zone of Weil

- Cell-rich zone

- Deep pulp cavity or Central zone

pulp
 Histology of THE PULP
1. Odontoblastic zone in the periphery

The most external area of the pulp.

Immediately underneath the prevention

It is composed by:

Body of the odontoblasts

Blood capillaries

Nervous fibers
 Histology of THE PULP
2. Cell-free zone of Weil

Very narrow area under the odontoblasts.

Relatively free of cells.

It is crossed by blood vessels, amyelinic nervous fibers and thin

fibroblast processes.

It may not be clear in:

Young pulps that form quickly dentin

Old pulps that produce reparative dentin

 Histology of THE PULP
3. Cell-rich zone

At the subodontoblastic area.

It presents:

High levels of fibroblasts

Some: Macrophages, lymphocytes, plasmatic cells

It is formed as a result the peripheral migration of the cells

that reach the central areas of the pulp. It starts at the
moment of the dental eruption.
 Histology of THE PULP
4. Deep pulp cavity or Central zone

PULP properly said.

It is a system of connective tissue formed by:

Fibroblasts that create the

Fundamental matrix (collagen and reticulin), that is a basis to

Fibrous complex

These is where the nervous fibers and blood vessels have the
biggest diameter.
 Histology of THE PULP
The blood vessels enter at the apex and suffer
ramifications at the pulp chamber.

The lymphatic vessels originate as small vessels

with thin walls at the coronal area of the pulp. We
differentiate them from the blood vessels thanks to
the absence of red blood cells in them.

The nerve fibers go inside the pulp through the apex

in company with the arteries.
 EvolUTION OF THE PULP
YOUNG PULP: Rich in cells and
poor in intercelluar substance

If there are more

aggressions,
caries the change is
TIME + MASTICATION
faster
The young pulp has a
bigger capacity of response

Elder PULP: More fibers and

less cells
Functions of the pulp
FUNCTIONS OF THE PULP
Formation of the dentin

Nutrition

Sensorial

Defensive immune cells

Total or partial conservation of the pulp

PULP: DENTIN FORMATION
The formation of the dentin is continuous and produces
modifications in the pulp chamber and pulp canals.

This process is more intense in the primary dentition than

in the permanent dentition.

Aggression
caries in young permanent dentition
Acceleration of the dentin production and of the closure
of the apical foramen

Aggression in primary dentition Accelerates the root

reabsorption
PULP: DENTIN FORMATION
A. PRIMARY DENTIN:

It extends from the limit of the enamel or the cement

up to the pulp.

It includes all the formation of the tooth (first the

crown and then the root)
PULP: DENTIN FORMATION
is deposited when the apex is closed
B. SECONDARY DENTIN and this needs 3 years

After the tooth it is formed, there is deposition of

dentin for the rest of the life

It is a slower deposition

The pulp chamber and root canals decrease in size

This dentin has the same structure as the primary

dentine but less mineralized Slightly less mineralized
 DEFENSE REACTIONS
AGAINST THE CARIES
C. TERTIARY DENTIN

Also called Reactional or reparative dentin.

It is produce by some king of aggression.

The pulp reacts quickly creating dentin in the

compromised area.

Its function is to stop the irritation.

 DEFENSE REACTIONS
AGAINST THE CARIES
SCLEROTIC DENTIN (TRANSLUCENT, TRANSPARENT
DENTIN)

When the aggression against the pulp is mild, sclerotic

dentin appears with the tertiary dentin.

Its mechanism of action is: The odontoblasts become

shorter, leaving free the dentine tubules. This dentin tubules
will become mineralized forming peritubular dentin.

The aim is to try to slow the advance of the caries by

diminishing the permeability of the dentin.
 DEFENSE REACTIONS
AGAINST THE CARIES
INFLAMMATORY AND IMMUNOLOGICAL
RESPONSE

The pulp in the primary dentition responds more

quickly to the dental caries than the permanent teeth.

Before the apparition of inflammatory changes in the

pulp, there is a reduction of the general size of the
pulp and of the number of odontoblasts.
Remember!! The pulp chamber is a closed spaced surrounded by hard
tissue and the pulp has terminal vascularization with a limited capacity of
response
agression reparative dentin Vascular dilation

Inflammatory cells Reversible pulpitis Irreversible pulpitis pulp necrosis

PULP DIAGNOSE
 PULP DIAGNOSE
A. GENERAL FACTORS

General state of the patient.

Important medical history: Extraction

Necessary premedication with antibiotics??

 PULP DIAGNOSE
Diseases and conditions where the pulp treatment is conterindicated in children.

1. Risk of infection

Congenit cardiopathies. Risk of infective endocarditis

Nefritis

Compromised immunity NO ENDO TREATMENT

- Leukemia

- Idiopathic cyclic neutropenia

- Process with depression of the polimorphonuclear leukocytes and granulocytes

Patients with very poor general health

- Solid tumors
 PULP DIAGNOSE
Realization of pulp treatments in children with
poor general health

Meticulous study of the child and the general state

Study of the pulp treatment

Evaluation of the relative importance of keeping the

affected tooth
 PULP DIAGNOSE
Diseases and conditions where the pulp treatment
is indicated in children more than an extraction.

1. Risk of hemorrhage

Coagulopathies

Hemorrhagic alterations
 PULP DIAGNOSE
B. REGIONAL FACTORS the acute response is
worst in children

Oral state of the patient.

Evaluation of the risk factors

Dental age

Presence of malocclusions

Strategic importance of the dental organ in the arch

Associated phenomenons (cellulitis, adenopathies,)

EXTRACTION AFTER
ANTIBIOTICS
Possibilities to reconstruct the tooth
 PULP DIAGNOSE
C. CONDUCTUAL FACTORS

During the anamnesis and clinical exploration we

have to keep in mind that we are treating a pediatric
patient that will either:

Really wants to
Does not want collaborate,
to collaborate, responding to
because of fear non-existent
or short age stimulus
 PULP DIAGNOSE
C. LOCAL FACTORS

To achieve a correct diagnose, we must support it on:

History of pain

Clinical exam

Radiographic exam
 PULP DIAGNOSE
Local factors: History of pain

The pulp pain is not always related with an altered state

of the pulp

Kinds of dental pain:

- Pain caused by heat, cold, sweet, mastication or

other stimulus that when are eliminated, the pain
disappears or diminishes. They indicate dentinal
sensibility to a deep caries or filtration of a
restoration. The harm is minimum and reversible
REVERSIBLE PULPITIS. MINIMUM PULP DAMAGE
 PULP DIAGNOSE
Local factors: History of pain

Kinds of dental pain:

- Spontaneous, continuous pain that appears in

moments of inactivity such as sleep. It indicates
advanced pulp harm, in most cases irreversible
IRREVERSIBLE
PULPITIS.
ADVANCED PULP
DAMAGE
 PULP DIAGNOSE
Local factors: History of pain

Kinds of dental pain:

- Story of various episodes of pain along the time.

NECROSIS

Advanced pulp degeneration or even loss of vitality.

The process may have extended to the surrounding
tissues
 PULP DIAGNOSE
Local factors. Clinical exam

Exam of all the soft tissues searching for:

Change in mucous color

Abscess, inflammation

Fistula
 PULP DIAGNOSE
Local factors. Clinical exam

Dental exam:

Evaluation of the depth and extension of the carious

process and fracture

Pulp expositions: Evaluate the type and quantity of

hemorrhage, size of the exposition and aspect of the pulp

Presence of polyps
 PULP DIAGNOSE
Local factors. Clinical exam

Dental exam:

Possibilities of rubber dam isolation

Dental mobility (differentiate between physiological and pathological

mobility)

Sensitivity to percussion or pressure

Vitality tests: Thermal and electric vitality tests (not very reliable in primary
dentition)

Change of color of the crown (necrosis)

 PULP DIAGNOSE
Local factors. Radiographic exam

Fundamental for the pulp diagnose.

Time remaining in the arch of the tooth

State of the permanent tooth in formation

Tooth anatomy

Relationship between the roof and floor of the pulp

chamber.
 PULP DIAGNOSE
Local factors. Radiographic exam

Depth of the lesion and its proximity to the pulp

chamber

Previous treatments

Pathological reabsorption: internal and/or external

Presence of pulpar calculus

Perforation of the pulp chamber ceiling

 PULP DIAGNOSE
The primary dentitions anatomy Makes it
easier the osteolysis of the inter-radicular
Parulis abscess area than the periapical area

Typical in primary teeth

they present in the furcation area
Very thin pulp chamber floor

Drainage of the infection

If the osteolysis is bigger than half the root or it affects the dental follicle of the
permanent tooth, we will do EXTRACTION.
There will be risk of hipoplasia, deviations from its position or even loss of the
permanent tooth
Aggression Reparative dentin Vascular dilation

Reversible pulpitis Inflammatory cells

Irreversible pulpitis
Pulp necrosis
Classification of pulp
pathology
 Classification of pulp
pathology
1. Asymptomatic pulp exposure (

2. Clinic pulpitis

2.1. Reversible pulpitis

2.2. irreversible pulpitis

3.Pulp necrosis.
 Classification of pulp
pathology
1. Asymptomatic pulp exposure.

Histology of chronic partial pulpitis (crown pulp) or not

No pain or other signs

No sensitivity to pressure or percussion

Normal dental mobility

Part of the pulp exposed during the preparation

Red pulp, controllable hemorrhage

No radiographic signs
 Classification of pulp
pathology
2. Clinic pulpitis (reversible)

Histology of partial pulpitis (crown pulp) or not

Provoked pain by stimuli and disappears quickly

No sensitivity to pressure or percussion

Normal dental mobility

Part of the pulp exposed during the preparation

Red pulp, controllable hemorrhage

No radiographic signs
 Classification of pulp
pathology
2. Clinic pulpitis (Irreversible)

Histology of chronic total pulpitis (crown pulp and

radicular pulp)

Spontaneous pain, sharp and persistent

Sensitivity to percussion and palpation

Maroon pulp with abundant hemorrhage

Hard hemostasia
 Classification of pulp
pathology
3. Necrosis

Signs of pulp degeneration

Abscess, fistulas

Pathological mobility

Perirradicular or interradicular radiolucid area

Absence of hemorrhage or partial hemorrhage

Bad smell
PULP TREATMENTS
 PULP TREATMENT
CONSERVATIVE OR VITAL PULP

Indirect pulp capping usually permant but some time primary

Direct pulp capping permanent

Pulpotomy
in permanet she means the one with open
apex so not yet closed
RADICAL OR NON-VITAL PULP

Pulpectomy

Apexification / revascularization permanent

Extraction