Modern methods of treating pulpitis. Features of the treatment of pulpitis of teeth with immature or resorbing roots

From this article you will learn:

treatment of pulpitis: methods,
how to remove a nerve from a tooth - video, stages,
Is it painful to remove a nerve from a tooth?

The term “pulpitis” usually refers to inflammation of the nerve in the tooth. The name of the disease is made up of the word “pulp” (the so-called neurovascular bundle inside the tooth) and the ending *it, which is used in medicine to indicate inflammation.

The main causes of pulpitis are: firstly, caries that is not cured in time (resulting in infection from carious cavity penetrates into the pulp of the tooth), and secondly, when the doctor, when treating caries, did not completely remove the tissues affected by caries, leaving them under the filling.

Pulpitis: symptoms

The main symptom that you have pulpitis is pain. Pain with pulpitis can be varying degrees severity - from minor pain, which is provoked by thermal irritants, to acute paroxysmal spontaneous pain, which makes you want to climb the wall.

Given the difference in symptoms, it is customary to distinguish two forms of this disease. Below we have described what symptoms pulpitis may have and treatment in some cases, by the way, may also depend on the form of pulpitis (the severity of symptoms).

Acute form of pulpitis –
This form is characterized by acute paroxysmal pain that occurs especially at night. It is typical that the pain increases, and the “pain-free” intervals become shorter and shorter. As a rule, pain occurs spontaneously, i.e. without the participation, for example, of thermal stimuli.
However, during the pain-free interval, in some cases it can be provoked by cold or hot water. With pulpitis, it is characteristic that after the removal of the irritant, the pain persists for about 10-15 minutes, which makes it possible to distinguish pain with pulpitis from pain with deep caries. With the latter, the pain stops immediately after the cessation of exposure to the stimulus.
Very often, patients cannot even indicate which tooth exactly hurts, which is due to the irradiation of pain along the nerve trunks. The pain increases due to the gradual transition of inflammation from serous to purulent. During development purulent inflammation in the pulp, the pain becomes pulsating and shooting, but the pain-free intervals almost completely disappear.
Chronic form of pulpitis –
in this form, inflammation is not pronounced. Patients usually complain of small aching pain, most often arising from exposure to thermal and cold stimuli. Sometimes, by the way, with this form of pain there may be no pain at all. Keep in mind that chronic form pulpitis can periodically worsen, and during periods of exacerbation of inflammation, the symptoms are exactly the same as in the acute form.

Treatment of pulpitis: methods

Treatment of pulpitis is most often carried out by depulping the tooth. This method implies complete removal nerve in the tooth, after which the doctor mechanically expands and then fills the root canals. In patients young(subject to contact early stage inflammation) it is possible to carry out treatment while preserving the living pulp of the tooth.

Of course, it is best to leave the nerve alive, because pulpless teeth become more fragile and change their color to a grayer color. However, in most cases, the use of pulpitis is impossible, because Patients extremely rarely come in when the first symptoms have just appeared, and also due to their age (the pulp is well restored in people under 25 years old).

Below we will talk in detail about traditional treatment pulpitis (read about the conservative method in the link above). By the way, according to official statistics Treatment of pulpitis is carried out poorly in 60-70% of cases, which requires subsequent retreatment of the tooth.

How to remove a nerve from a tooth - video, stages

This method is traditional. Its essence lies in the following steps:

drilling out all tissues affected by caries (Fig. 2),
removal of the tooth nerve (carried out using a special instrument),
mechanical expansion of channels (Fig. 3),
filling of tooth root canals (Fig. 4),
filling the coronal part of the cube (Fig. 5).

Treatment of pulpitis: stages of tooth depulpation

Below we will describe in more detail each stage of the treatment of pulpitis; perhaps this information will help you identify a freeloader dentist and prevent poor-quality treatment and its complications.

Treatment of pulpitis: video of nerve removal from a tooth

The first video clearly shows how the pulp is removed (time - 1 minute 5 seconds), the second video shows how the canals are mechanically treated with a special endodontic tip, and then they are filled.

Algorithm for the treatment of pulpitis using a specific example -

If you have pulpitis, treatment of a single-rooted tooth with one canal is usually carried out in two visits (at the second visit a permanent filling is already placed). In multi-rooted teeth, which have significantly large quantity channels (from 2 to 4) – treatment of pulpitis is carried out in 3 visits.

The rule is categorical: a permanent filling on a tooth is not placed in the same visit as the root canal filling, i.e. filling material in the channels must first harden, and the moisture from it evaporate. Only after this can a permanent filling be placed. Below we will look at the algorithm for treating pulpitis of a multi-canal tooth in three visits.

First visit:

1. Anesthesia or is it painful to remove a nerve from a tooth -

How painful is it to treat pulpitis: It is definitely very painful if you decide to do it without anesthesia. Fortunately, they can completely solve this problem. If you feel pain after anesthesia, this can only be due to the fact that the doctor administered the anesthesia poorly. This usually happens when trying to numb large molars on lower jaw, because Mandibular anesthesia, which is complex in technique, is administered there.

2. Drilling out all carious tissues with a drill -

Firstly - at this stage everything is deleted carious tissue. Secondly, healthy tooth tissues are also partially removed, namely all tooth tissues above the pulp chamber and the mouths of the root canals. This is necessary to ensure visualization of the root canal orifices and ease of their processing with instruments.

In Fig. 6-7 you can see the boundaries of excision of hard tooth tissues in the treatment of pulpitis. Figure 8 shows a view of the root canal mouths after they have drilled into the required amount of tooth tissue.

3. Isolation of the tooth from saliva –

This is done using a rubber dam. Isolation is necessary to prevent infection from the oral cavity from getting into the root canals along with saliva. This is standard international practice, but in Russia a rubber dam can often be seen only when a doctor fills a tooth.

4. Removal of pulp from the tooth crown and root canals –

It is necessary to measure each channel in turn, because Each channel length is unique and there are no standards. After the measurements are completed and the data is recorded, K-files are simultaneously inserted into all channels (each to its own depth), and a control is made X-ray(Fig. 11). The apex locator sometimes makes mistakes, so the x-ray will show how accurately the length of the canal was measured and whether adjustments are needed.

6. Mechanical processing of channels –

Usually carried out with manual files (K-files or reamers). In Fig. 13 you can see the K-file in the root canal. The dentist rotates this instrument by the handle with his fingertips, and the cutting edges of the instrument excise chips from the walls of the canal, expanding it. The purpose of mechanical treatment is to widen the canal so that later it can be properly filled.

Second visit:

By the way, it is preferable to fill root canals without anesthesia, but this is not necessary. This is due to the fact that if a slight pain occurs when filling the canals, the doctor immediately understands that he has moved the gutta-percha pin beyond the apex of the root. Accordingly, the doctor can change the filling depth in time.

Removing a temporary filling.
Flushing the canals with antiseptics.

Filling canals with gutta-percha and sealer –
After the root canals are washed and dried, they must be sealed tightly. This is done using gutta-percha pins. different sizes(Fig. 16) and sealer (this is something like a paste). The pins are inserted into the root canals and compacted there. In Fig. 14-15 you can see the mouths of the root canals Before and After the canals were filled with gutta-percha.
X-ray control of filling (required!!!)
If everything is OK on the x-ray, we proceed to the next stage. But, if we see that the canal is not filled up to the apex, or the gutta-percha pins extend beyond the root into the surrounding tissues, it is necessary to remove all the gutta-percha pins and start filling the canals all over again. In Fig. 17-19 you can see well-sealed root canals (all root canals are sealed to the apex of the root).
Unfortunately, it is worth noting that the vast majority of dentists, even if they see that the root canals are not filled, do not redo the work. The percentage of poor-quality treatment of pulpitis that we announced at the beginning of the article is connected with this.

At the end of the visit, a temporary filling is placed, and the patient is warned that the tooth may begin to hurt after undergoing anesthesia. Good ones will help relieve pain. A little pain is the norm, because during instrumental work in canals, K-files slightly injure the tissue in the area of the root apex.

Third visit:

This visit is entirely dedicated to the production. We have already said that under no circumstances should filling the crown of a tooth be performed at the same visit as filling the root canals. First, the contents in the root canals must “set” and harden. Only after this can you begin to restore the tooth crown. But many doctors save their time and violate treatment rules.

Removal of a tooth nerve: consequences

If the nerve of a tooth is removed, the consequences arise within the first few months. Firstly, the tooth becomes a little more fragile. This is due to the fact that blood vessels are removed from the tooth along with the nerve, which leads to the disappearance of “moisturizing the tooth tissue from the inside.”

Secondly, pulpless teeth change their color slightly. They become grayer and lose their shine a little, i.e. the enamel becomes duller. But there are cases when, after removal of the nerve, the teeth become bluish in color. This is unnatural and is due to gross mistakes dentist when filling root canals. In particular, this happens when, at the time of introducing the filling material into the root canal, there is blood there (which absolutely should not be there).

Pulpitis: treatment with folk remedies

Separately, I would like to say about the treatment of pulpitis using homeopathy and remedies traditional medicine- herbs, lotions, rinses...

Pulpitis is next stage caries development. Pulpitis develops as a result of the penetration of cariogenic microorganisms from the carious cavity into the pulp of the tooth. Caries is an irreversible process - once a tooth defect has occurred, it cannot be cured otherwise than by removing rotten carious tissue. Therefore, all tissues affected by caries are drilled out of the tooth, and then the defect is filled.

Cariogenic microorganisms, having got from the carious cavity into the pulp, cause inflammation in it. Studies have shown that cariogenic microflora is very resistant to any anti-inflammatory drugs, even antibiotics. For example, insensitivity to Ampicillin reaches 99.99%, and about 95% of cariogenic microflora are insensitive to Lincomycin. What can we say in this case about herbs and lotions...

Pulpitis permanent teeth

Acute serous pulpitis

Pulp hyperemia, acute traumatic pulpitis (accidentally opened pulp horn), acute serous limited pulpitis, as well as acute serous diffuse pulpitis in teeth with formed roots, when the disease is no more than a day old and when the carious cavity is localized on the chewing or proximal surface located above the equator teeth, in healthy and practically healthy children treated biologically. Prerequisite for conservative therapy These forms of pulpitis provide good resistance to infection of the pulp of permanent teeth in children. During the period of unformed root with the same forms of pulpitis, the prognosis is less favorable due to the fact that inflammatory process spreads to the tissue of the growth zone of the tooth root.

On the first visit, after application anesthesia, necrotomy and formation of a carious cavity are carried out, thorough antiseptic treatment is carried out in compliance with the rules of asepsis and antisepsis. It is very important to isolate the carious cavity from saliva.

If the tooth cavity is not macroscopically opened, there is no need to open it with a bur, since the thinned, demineralized layer of dentin with wide straight dentinal tubules at the bottom of the carious cavity cannot serve as an obstacle to the outflow of inflammatory exudate and diffusion medicines. Opening a tooth cavity with a bur will certainly lead to additional injury and infection of the inflamed pulp. It is almost impossible to ensure painlessness of this manipulation in children, which negatively affects the child’s attitude towards treatment. Antimicrobial agents are used for antiseptic treatment wide range actions and having a pronounced anti-inflammatory effect: antibiotics local action in combination with proteolytic enzymes, mephenamine solution sodium salt, chlorophyllipt, ectericide.

The cavity is dried with sterile cotton swabs and pastes containing glucocorticoids are applied for 1-2 days, and the tooth is covered with an airtight bandage without pressure, for which artificial dentin mixed with water is used.

Glucocorticoid drugs are especially indicated in cases where inflammation in a closed cavity occurs with severe allergic component. In these cases, glucocorticoids in combination with antibiotics are used in the treatment of pulpitis.

Pharmacotherapy of pulpitis should be carried out through the combined use of several drugs that have a pronounced anti-inflammatory, antiallergic and dentinogenic effect. Pastes with glucocorticoids, which also contain an antibiotic and an anesthetic substance, are applied for 1-2 days, and subsequently they are replaced with odontotropic paste.

You can use domestically produced Oxyzon pastes containing hydrocortisone and oxytetracycline base; "Hyoxyzone", which contains hydrocortisone and oxytetracycline chloride.

On the second visit, if there is no pain in the tooth, the bandage is removed and antiseptic treatment is performed. Having previously isolated the carious cavity from saliva, dry it with sterile cotton swabs, apply a medicinal paste, an insulating lining made of phosphate cement and fill the tooth.

Therapeutic biological pastes must contain drugs that favor the preservation of pulp viability; they must have good solubility in water, pH>12, close to the pH of healthy pulp, high efficiency in small concentrations, long-lasting antimicrobial action, well injected into the carious cavity and be adhesive to dentin. These products should not have a toxic or irritating effect on tooth tissue.

Currently, substances with odontotropic effects are used in the form of varnishes, which are introduced into the carious cavity in liquid form (TresioIan) and in the form of hardening pastes. The most popular pastes contain calcium hydroxide, which stimulate the formation of replacement dentin and the mineralization of softened dentin at the bottom of the carious cavity. Already 42 days after their use, replacement dentin is formed.

The best results were obtained after using pastes containing calcium hydroxide with a pH>12. Preparations with a pH of 10.5 or lower have toxic effect to the pulp.

In teeth with immature roots and in cases where there are contraindications for biological treatment, acute serous forms Pulpitis of permanent teeth is treated by vital pulp amputation. In case of acute serous diffuse pulpitis, subtotal extirpation is performed, the so-called high amputation pulp. It is believed that calcification occurs in the remaining part of the root pulp after the elimination of the inflammatory process.

On the first visit, anesthesia is performed - when treating large and small molars, it is used conduction anesthesia, and when treating incisors and canines, infiltration anesthesia with lidocaine solutions is sufficient. After anesthetizing the pulp, the carious cavity is prepared, the tooth cavity is opened with a sharp excavator or a spherical bur, the crown pulp is removed, antiseptic treatment is carried out and bleeding from the pulp stump is stopped. Then a biological paste, an insulating lining and a permanent filling are applied. Selection of means for antiseptic treatment and medicinal pastes carried out in the same way as in the treatment of pulpitis using a biological method.

After subtotal extirpation of the pulp, the tooth root canal is filled with pastes based on calcium hydroxide.

Required condition successful treatment is compliance with the rules of asepsis and antisepsis.

To stop bleeding from the pulp stump, hemophobin, aminocaproic acid, thrombin, and feracryl are used.

Hemophobin(Haemophobin) - a solution of pectins in an isotonic sodium chloride solution (1.5% solution for injection and 3% solution with the addition of 1% calcium chloride for oral administration and applications). A tampon moistened with hemophobin solution is applied to the bleeding area until the bleeding stops.

Aminocaproic acid(Acidum aminocapronicum). Synonym: Epsilon-aminocaproic acid. As an inhibitor of fibrinolysis, it is used for bleeding associated with increased activity of the fibrinolytic process. Reduces capillary permeability by inhibiting the activity of hyaluronidase. It is used to stop bleeding from the pulp during vital amputation and extirpation.

Thrombin(Thrombinum) is obtained from donor blood plasma. Thrombin solution is used only topically to stop bleeding from small capillaries, alveolar bone, gum mucosa or tongue. Before use, the contents of the ampoule are dissolved with sterile isotonic solution sodium chloride (amount indicated on the label). Impregnated with thrombin solution hemostatic sponge or a gauze swab and apply it to the bleeding wound until the bleeding stops.

Feracryl(Feracrilum) is the iron salt of polyacrylic acid. The drug has a local hemostatic effect, pronounced antimicrobial effect for gram-positive and gram-negative bacteria, including those resistant to other antibiotics. Immediately after exposure to a 1% solution on a staphylococcus culture, the death of 96% of microorganisms is noted, and after a day - almost 100%. It has a moderate local anesthetic effect.

The possibility of using feracryl to stop bleeding is due to its ability to form complexes with blood proteins, without affecting its coagulation factors. Concomitant use A 1% solution of feracryl with aminocaproic acid is contraindicated.

In case of bleeding during amputation or extirpation of the pulp, a swab moistened with feracryl solution is lightly wrung out and applied to the mouth of the tooth root canal or inserted into the canal on the turunda. After 1-2 minutes, the tampon or turunda is removed. If necessary, this manipulation is repeated until the bleeding stops completely.

Children who have undergone treatment of pulpitis using a biological method or the method of intravital pulp amputation in the period until the end of root formation, the formation of a dentinal bridge or stable stabilization of the pulp condition need medical rehabilitation. The first control visit is scheduled after 10-14 days, then after 3, 6 months and after 1 year.

Acute serous diffuse pulpitis of permanent multi-rooted teeth with formed roots is treated by vital or devital pulp extirpation.

The advantage of the methods of vital amputation and pulp extirpation is the absence of the toxic effect of devitalizing agents on the periodontium. The need for vital pulp amputation in children to relieve pain, and in the case of vital extirpation, to stop bleeding from the root canal has led to the fact that these methods are used quite rarely, especially in the context of planned sanitation. During vital extirpation, tooth root pulp is removed after diathermocoagulation, which avoids bleeding from the root canal. To do this, use the DK-1 device, device power 4.74 W (current 60 mA, voltage 50-60 V), exposure 3 s. After coagulation, the pulp is removed using a pulp extractor. Pulp devitalization is carried out with arsenic or paraformaldehyde paste.

After devital amputation, the pulp stump is treated with resorcinol-formalin liquid and resorcinol-formalin paste is applied to mummify the root pulp.

After devital extirpation of the pulp of permanent teeth, antiseptic treatment of the tooth root canal is carried out with a 3% solution of hydrogen peroxide or solutions of nitrofuran drugs. You should not use a 2% chloramine solution for antiseptic treatment of the tooth root canal, as it has a cytotoxic effect and leads to the development of an inflammatory process in the apical periodontium in the short term, which adversely affects the long-term results of treatment of pulpitis.

Mechanical treatment of the tooth root canal is mandatory, which involves removing infected predentin from the walls of the tooth root canal. For this purpose, use a root rasp or a pulp extractor of the appropriate diameter. The root canals of the tooth are filled within the opening of the tooth apex with plastic materials or materials based on artificial resins, often in combination with pins.

Plastic hardening filling materials differ in their physical properties. These include hardening pastes, cements, chlorine-percha, amalgams, and materials based on epoxy resins.

Hardening pastes do not have a fat base; they are used as a plasticizer to ensure their soft consistency. aqueous solutions: 50% solution of calcium chloride, 2% solution of novocaine, solutions of hexamethylenetetramine (urotropine), etc. As the solution evaporates, the paste hardens, but often becomes permeable to tissue fluid.

Sulfocalcium paste contains zinc oxide - 10.0, norsulfazole - 5.0, calcium phosphate - 2.5, bismuth nitrate - 2.0. The liquid is a 50% saturated solution of calcium chloride. The pasta can be prepared in advance.

The cements used to fill the tooth root canal are of two types - phosphate and zinc-eugenol. To fill the root canal of a tooth, liquid-mixed zinc-phosphate cement is used. It hardens quickly, does not dissolve in the root canal, is not a breeding ground for bacteria, does not stain the tooth, and is radiopaque.

Amalgams are rarely used for filling the root canal; more often they are used for retrograde filling of the canal during resection of the root apex.

Filling materials based on artificial resins

The resorcinol-formalin mixture is prepared from an aqueous saturated solution of resorcinol, a 40% formaldehyde solution, which are mixed in equal proportions before filling (2 drops each), a 10% sodium hydroxide solution (1 drop) is added as a catalyst. However, this mixture does not satisfy a number of requirements: it is reduced in volume, stains tooth tissue, is not radiopaque, and excess formaldehyde causes periodontal irritation. Introduction of thymol and acetic acid somewhat accelerates condensation, and fillers - zinc oxide, phosphate cement powder, barium sulfate give the mass X-ray contrast. However, it has not yet been possible to achieve full compliance of the material with the requirements placed on it.

Bakelite paste suggested by M. M. Weisbrem, also refers to artificial resins obtained by processing phenols or cresols. The jelly-like polymer obtained as a result of polymerization is dissolved in 96% alcohol to a syrupy consistency. To prepare the paste, take 2-3 drops of liquid and mix with bismuth carbonate. The paste is easy to introduce and remove (dissolves with ethyl alcohol), is bactericidal, sticks to the canal walls, is insoluble, does not stain the tooth, is radiopaque, does not shrink.

Ribler paste is a material related to bakelizing pastes - phenolic resins. The plastic mass obtained by mixing powder and liquid hardens over time as a result of polycondensation in the presence of ionized sulfuric acid. In the polycondensation phase, the material undergoes dissolution and in the same period of time (24 hours) it has the most pronounced bactericidal effect. The hardened material forms a homogeneous dense mass that does not dissolve, does not absorb the dye solution, does not change volume, and is radiopaque.

Paracin cement is obtained from resorcinol-formaldehyde resin. The package contains two liquids: artificial resin, hardener and powder - zinc oxide with a plasticizer. To prepare cement, apply 2 drops of resin and hardener using various pipettes and pour in the powder. The liquids are mixed and the powder is added to them. Polymerization begins after 30 minutes, ends after 30 hours.

Guaiacryl, proposed by O.I. Kruglyakov, consists of powder - zinc oxide and liquid - 6% solution of methyl methacrylate in guaiacol (a derivative of eugenol). Polymerization begins after 25 minutes, ends after 60 minutes. Easy to administer, non-viscous, radiopaque.

Timoplast, proposed by I. Khinkov, contains acrylic quick-hardening plastic powder with the addition of silver amalgam sawdust. Eugenol is used as a solvent and plasticizer, thymol is added as an inhibitor. The material is prepared ex tempore (mixed on a glass plate heated to 60-900C), retains plasticity for 15-20 minutes, and has a bactericidal effect.

Placid, proposed by A. Kodukova, K. Kevorkyan, E. Atanasova, consists of a powder containing equal parts of a quick-hardening plastic polymer, zinc oxide, bismuth carbonate and liquid - eugenol with the addition of 3-5% thymol. The powder and liquid are mixed ex tempore.

Tsebanite is an expanding filling material, proposed by G. D. Ovrutsky. It consists of a sinter of barium peroxide and potassium nitrate, as well as a filler consisting of white clay, iodoform and phosphate cement powder. Mix the powder with liquid phosphate cement. The start of polymerization is after 4-5 hours, the material is bactericidal.

Calmecin, calcin paste is a filling material based on calcium hydroxide. The use of these materials for filling the root canal involves stimulating the plastic function of the periodontium. The creation of a “biological filling” - a barrier of dentin-like tissue in the deltoid branches of the canal of the root apex - occurs as a result of metaplasia of the pulp tissue remaining there or during the transformation of periodontal tissue grown into the hole of the tooth apex.

Solid filling materials - pins made of silver, copper, gutta-percha, plastic, are used to fill the root canal only in combination with plastic materials. The introduction of a pin into the root canal of the tooth ensures a tighter fit of the filling mass to the walls of the canal, promotes its advancement to the hole in the apex of the tooth, and facilitates and speeds up the filling. In addition, silver and copper pins have an oligodynamic effect.

When using gutta-percha pins, before inserting them into the canal, they are moistened in chloroform, which dissolves the surface of the pin and forms a monolithic hardening mass with it. The disadvantage is the ability of gutta-percha to swell in water.

Tooth pain is deservedly considered one of the most severe and debilitating. It is very difficult to ignore, and not every medicine can cope with it. In addition, the inflammatory process localized in the tooth can become very complicated in the absence of proper and timely therapy. And as a result, a visit to the dentist will still become inevitable. The topic of our conversation today will be the treatment of pulpitis of permanent, immature and temporary teeth.

Pulpitis of temporary teeth

Today, many parents are confident that there is no need to treat temporary baby teeth, because they will fall out anyway. But this point of view is one hundred percent wrong, because in the absence of adequate therapy, caries can be complicated by dental pulpitis, and this condition can cause a lot of suffering to the baby. Therefore, readers of Popular Health need to closely monitor the condition of their children’s baby teeth and promptly treat them.

By pulpitis we mean acute inflammation, affecting those soft fabrics and neurovascular formations that fill dental cavity. There are several main approaches to its therapy. Thus, pediatric dentists of many budgetary organizations prefer the antediluvian method of devital amputation, when an arsenic paste or a devitalizing paste that does not contain arsenic is placed on the exposed nerve. With this method of therapy, there is no need to use instruments on the canals of baby teeth, which is considered to be somewhat gentle on the child’s psyche. On the second visit to the doctor, the doctor pumps baby tooth resorcinol-formalin mixture, and then paste.

Thanks to this, the infected and “killed” pulp is mummified, which in turn prevents its decomposition. Next, a permanent filling is placed on the temporary tooth.

However, the use of devitalizing paste or arsenic paste has a number of disadvantages:

The treated tooth changes color over time, becoming pink and sometimes even brown;

The paste forms a plug in the canal, which is why the tooth cannot be treated again if the need arises;

The paste helps to solder the roots of the tooth to the surrounding “bones”, which can make it difficult to remove or natural loss tooth

Modern dentists prefer treating teeth with pulpitis using the method of vital or devital extirpation, removing the nerve from the canal. Afterwards, the canals are filled with a paste with anti-inflammatory properties, which over time can be absorbed along with the roots (when a temporary tooth is replaced).

The agent of choice for root filling most often is zinc eugenol paste, excellent option may become a foreign product - Magipex.

Some dentists prefer vital amputation when treating pulpitis of primary teeth. In such a situation, doctors remove only the upper (coronal) part of the nerve, placing a special medicine on the root pulp. After the pain stops, a permanent filling is placed on the baby tooth.

Maintaining pulp vitality is preferable since the pulp supplies the tooth with nutrients, and it remains highly durable. When the nerve is removed, the tooth, on the contrary, becomes fragile over time.

How are permanent teeth with pulpitis treated??

Pulpitis of permanent teeth is a fairly common problem among patients. of different ages. There are two main approaches to its therapy:

Biological (when the vitality of the pulp is preserved);

Amputation (when part of the nerve is removed);

Extirpation (when the entire pulp is removed).

Performance biological treatment possible only with early application medical care. In such a situation, doctors open the affected tooth, treat the pulp with an antiseptic, apply the above-mentioned calcium hydroxide paste on top and install a temporary filling. After the cessation of pain and medical (x-ray) control, the filling is replaced with a permanent one. This method requires high professionalism of the doctor and one hundred percent sterility.

Basically, in our clinics, doctors prefer to completely remove the entire pulp using the vital extirpation method. Doctors remove dental tissues affected by caries, then penetrate into the canals using special thin needles. With them, he removes the inflamed nerve, while simultaneously treating it with antiseptics. Next, the doctor fills the canals and installs a permanent filling.

How is immature teeth treated??

When temporary teeth are replaced by permanent ones, the roots of the erupted teeth do not form immediately. They begin to form only after the tooth has erupted, and this period can last from three to nine years. And the treatment of teeth with an immature root system differs from the treatment of permanent formed teeth.

For pulpitis on unformed teeth, doctors prefer to preserve the vitality of the pulp by using the method of biological treatment or vital pulpotomy (when the coronal pulp is removed, but the root pulp remains viable). This allows you to preserve the functionality of the tooth and ensure further full formation of the root system.

But in some cases, preserving the root pulp becomes impossible, so partial amputation or complete extirpation is carried out. For further treatment, dentists fill the root canal with a non-hardening paste containing calcium hydroxide and place a temporary filling on top. Only after the x-ray confirms that the formation of the tooth’s root system is complete, doctors remove the calcium hydroxide paste and perform a filling using permanent materials.

When treating pulpitis of temporary, permanent and immature teeth, it is extremely important not to hesitate and to seek medical help immediately after pain occurs.

Introduction. Treatment of permanent teeth with immature roots is always a difficult task for the dentist. This is due to the complex anatomy of the unformed root, when the apical part has the shape of a bell. The basic principle of treating teeth with immature root apex is to long-term preservation pulp vitality until the process of root apex formation is completed.

Treatment of pulpitis of permanent immature teeth in children. Modern methods Pulp therapy for permanent teeth with incomplete root formation include: 1. Conservative biological method, indirect pulpotherapy method, direct pulp capping method 2. Surgical vital amputation, devital amputation or pulpotomy (deep amputation)

When choosing a treatment method for the inflamed pulp of permanent teeth in children, it is necessary to take into account a number of factors: the form of pulpitis; data on electrical excitability of the pulp; degree of caries activity; stage of root formation; general state child health; psycho-emotional status of the child.

Conservative methods. Indirect Pulp Capping – This indirect capping method avoids accidental exposure of the pulp when removing deep diseased dentin. Goal of treatment: stimulation of dentinogenesis, maintaining the viability of the entire pulp. Indications: deep caries (deep carious cavities without clinical symptoms inflammation of the pulp); pulp hyperemia.

Conditions ensuring the success of treatment: The tooth must be vital. Pulp without inflammatory phenomena. All infected, softened dentin from the walls of the cavity must be removed; nothing may be left at the bottom of the carious cavity. a large number of softened (demineralized and possibly somewhat infected dentin, capable of remineralizing and under which secondary replacement is produced (synonyms reparative, tertiary). Medical pad should have antibacterial, anti-inflammatory and stimulating dentinogenesis effects.

Technique: R-logical study to determine the zone of pulp closest to the bottom of the carious cavity. Removal surface layers carious dentin with an excavator without anesthesia until the first signs are obtained pain sensitivity. Local anesthesia. Careful preparation of the walls of the carious cavity, sparing the bottom.

Drying the cavity. Applying zinc oxide eugenolic or calcium hydroxide containing paste to the bottom of the cavity, for example: Jife, Dycal, Ultra-blend Calcimol. Restoration of the tooth crown (delayed filling). If during treatment it turns out that there is no potential danger of opening the tooth cavity after removing carious dentin, the prepared dentin is hard, with minimal changes color, no repeat visit is required and treatment can be completed in one visit.

Repeated visit after 6-8 weeks-6 months (but not earlier than 6-8 weeks, the time of the most active formation of replacement dentin). The following is carried out: X-ray and clinical monitoring of the formation of replacement dentin: the filling is removed; additionally prepare the bottom of the carious cavity in the presence of remaining softened dentin; Permanent restoration is carried out. But it should be remembered that when preparing a carious cavity, there is always a risk of opening the pulp

Indications: Accidental exposure of pulp no more than 1 mm in diameter during the preparation of a carious cavity in the treatment of dentin caries; Complicated fracture of the tooth crown with opening of the tooth cavity (up to 1 mm in diameter, if no more than 6 hours have passed since the injury). Clinical (up to 1 mm in diameter) and/or radiological opening of a tooth cavity of carious origin, provided there are no complaints of spontaneous pain, long-term pain from temperature and mechanical stimuli, as well as radiological changes in the periodontium (method of choice).

Biological method. The method of choice for the treatment of pulpitis in permanent teeth with incomplete root formation is a biological method that allows the entire pulp to be preserved viable. The basis for the method is the ability of young pulp, the so-called. “immature” permanent teeth to regeneration, due to the histological features of its structure.

Indications: accidental exposure of the pulp during preparation during the treatment of dentin caries, acute mechanical injury tooth (fracture of the tooth crown with opening of the tooth cavity); acute serous pulpitis in the absence of symptoms acute periodontitis; chronic fibrous pulpitis exacerbation of chronic fibrous pulpitis (if exacerbations occur no more than 1-2 times a year and without symptoms of acute periodontitis). exacerbation of chronic fibrous pulpitis for the first time.

In the immediate period after treatment, the criteria for successful treatment of pulpitis in children are clinical data: Absence of pain (spontaneous, nocturnal, from thermal irritants and when biting). Painless percussion; Mucous membrane without visible pathology Positive dynamics of EDI data during observation

In the long term after treatment, the effectiveness of the treatment methods is assessed on the basis of clinical data: No pain The color of the tooth crown has not changed Painless percussion The mucous membrane is without pathology EDI indicators do not differ from a similar tooth on the opposite side of the jaw R-logical data: 1.continuation of root formation ( root growth in length, closure of the apical foramen, narrowing of the canal); 2.formation of replacement dentin, closing the perforation hole; 3. absence of internal and external resorption of the root/roots and destructive changes in the apex area.

Treatment goals: Preservation of viability (vitality) of the root pulp. Continued formation of the root/roots (apexogenesis). Indications: Same as for the biological method (method of choice). The occurrence of complications during treatment with conservative methods. Chronic hyperplastic pulpitis (method of choice). It is technically impossible to perform the method of direct pulp capping in case of a complicated fracture of the tooth crown due to the peculiarity of the fracture line.

Preliminary radiography Anesthesia Preparation of a carious cavity taking into account the topography of the tooth cavity. Opening of the tooth cavity. Amputation of coronal pulp. Assess and control bleeding. Dry the cavity using sterile cotton balls. Calcium hydroxide paste for direct coating, zinc eugenol paste or zinc oxide eugenol cement are applied to the canal mouths. Restoration of the tooth crown.

Criteria for successful treatment using the vital amputation method: Clinical criteria do not differ from those for conservative methods treatment. X-ray: –narrowing of the root canals; – root growth in length; – formation of a dentinal bridge; – closure of the apical foramen; absence of calcifications in the lumen of the canal; internal and external resorption, destructive processes in the area of furcation and root apexes

Indications: The same as for vital amputation, but in the absence of the opportunity to create conditions that ensure a favorable outcome of treatment due to the psychosomatic characteristics of the child in the absence of material and technical capabilities or in the presence allergic reactions for painkillers. The treatment method does not differ from that used in the treatment of pulpitis of primary teeth.

Vital extirpation method (pulpectomy, biopulpectomy) Indications for pulpectomy are significant degenerative changes in the root pulp: acute purulent pulpitis; chronic gangrenous pulpitis; exacerbation chronic pulpitis with symptoms of acute periodontitis; chronic and exacerbation of chronic pulpitis, in the presence of R-logical changes in the periodontium.

Treatment of pulpitis of teeth with unformed roots using the extirpation method presents certain difficulties, which is primarily due to the structural features of the roots: short roots; wide canals and apical openings; the apical part of the root is made of a “growth zone”, which ensures the formation of the root and apical foramen, trauma to the tissues of which can lead to its death. Therefore, endodontic manipulations must be carried out carefully and carefully. Instruments and filling material should not extend beyond the beginning of the expansion of the apical foramen.

Technique: X-ray monitoring of the condition of the peri-apical tissues and the length of the formed root. Anesthesia. Preparation of a carious cavity, taking into account the topography of the tooth cavity, removal of all necrotic dentin. Opening of the tooth cavity. X-ray determination of root length (preferably using a reverse cone gutta-percha pin).

An important condition successful endodontic manipulation is correct definition extirpation depths. The pulp should be removed at the level of the beginning of the expansion of the apical part of the root. The pulp is extirpated, not reaching the apex of the tooth root by 1.5-2 mm. This manipulation is carried out very carefully, with minimal trauma to the remaining pulp stump.

Canal filling. The pulp stump is covered with Ca(OH)2-containing preparations (“Endocal”, “Calcicur”, “Biocalex”, “Kalasept”, “Apexdent”, etc.) followed by filling the canal with a paste based on zinc oxide and eugenol or its foreign analogues(“Endobtur”, “Endomethasone”, “Estezon”, etc.). Adding a layer of zinc oxide eugenol cement, water-based dentin or other insulating liner. Final tooth restoration with permanent filling material.

Criteria for successful treatment: Clinical data are the same as for other treatment methods. R-logical: root growth in length and closure of the apical foramen. After the completion of root formation and radiological confirmation of the closure of the apical foramen, it is recommended to carry out final filling of the canals using the classical technique using gutta-percha pins.

Damage to the pulp of permanent teeth due to caries or trauma remains common in children. Permanent teeth that continue to develop roots and have not closed the apex are called immature teeth. Once apical closure occurs, these teeth are considered to be fully rooted.

A permanent tooth with unformed roots due to pulp necrosis has an unfavorable prognosis, which in the future can lead to premature loss of such a tooth. Endodontic treatment of such teeth presents some difficulties, which will be described below.

From the above it follows that treatment of permanent teeth in children should be aimed at preserving the vitality of the pulp and creating conditions for the continued development of roots and the physiological formation of dentin.

Pulp-dentin complex of permanent teeth in children

Just as it was described for primary teeth, the most important and difficult aspect in the treatment of pulp pathology is to determine its viability and stage of inflammation. The pulp of permanent teeth in children contains a large number of cells and blood vessels, which contributes better healing compared to permanent teeth in adults. The degree of root development in these teeth determines the factors that will be taken into account when creating a treatment plan.

As in dairy, in children's permanent teeth tertiary dentin is deposited as a response of the pulp to caries or surgery.

The dentin matrix is thought to be a reservoir for bioactive molecules and growth factors that have been sequestered during dentinogenesis. As a result of damage to the dental tissue (for example, caries or acids produced by bacteria), these molecules can be released from the dentin along with other components of the extracellular matrix, triggering the formation of tertiary dentin. Representatives of the superfamily of transforming growth factors, in particular TGF-ps, have received considerable attention regarding their effect on mesenchymal cells and stimulation of dentin regeneration. It is believed that these bioactive molecules serve as a signal to attract progenitor stem cells to the site of pulpal injury, followed by their proliferation and differentiation, thereby initiating tissue regeneration and dentin bridge formation.

Pulp exposure in permanent teeth in children occurs primarily due to caries or trauma.