{\rtf1\ansi\deff1\adeflang1025
{\fonttbl{\f0\froman\fprq2\fcharset204 Times New Roman;}{\f1\fswiss\fprq0\fcharset0 Futura-Bold;}{\f2\fswiss\fprq2\fcharset204 Arial;}{\f3\fswiss\fprq0\fcharset0 Futura-Bold;}{\f4\froman\fprq2\fcharset128 Times New Roman;}{\f5\fnil\fprq2\fcharset204 SimSun;}{\f6\fnil\fprq2\fcharset204 SimSun;}{\f7\fswiss\fprq0\fcharset0 Futura;}{\f8\froman\fprq0\fcharset0 Palatino-Roman;}{\f9\fswiss\fprq2\fcharset204 Calibri;}{\f10\froman\fprq2\fcharset204 Times New Roman CYR;}{\f11\fnil\fprq2\fcharset204 Mangal;}{\f12\fnil\fprq0\fcharset204 Mangal;}}
{\colortbl;\red0\green0\blue0;\red0\green0\blue128;\red128\green128\blue128;}
{\stylesheet{\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049\snext1 Normal;}
{\s2\sb240\sa120\keepn\rtlch\af11\afs28\lang1081\ltrch\dbch\af5\langfe1049\hich\f2\fs28\lang1049\loch\f2\fs28\lang1049\sbasedon1\snext3 Title;}
{\s3\sa120\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049\sbasedon1\snext3 Body Text;}
{\s4\sa120\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049\sbasedon3\snext4 List;}
{\s5\sb120\sa120\rtlch\af12\afs24\lang1081\ai\ltrch\dbch\langfe1049\hich\fs24\lang1049\i\loch\fs24\lang1049\i\sbasedon1\snext5 caption;}
{\s6\rtlch\af12\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049\sbasedon1\snext6 Index;}
{\s7\sb240\sa120\keepn\rtlch\af2\afs28\lang1081\ltrch\dbch\af6\langfe1049\hich\f2\fs28\lang1049\loch\f2\fs28\lang1049\sbasedon1\snext3 Title;}
{\s8\sb240\sa120\keepn\qc\rtlch\af11\afs28\lang1081\ai\ltrch\dbch\af5\langfe1049\hich\f2\fs28\lang1049\i\loch\f2\fs28\lang1049\i\sbasedon2\snext3 Subtitle;}
{\s9\sb120\sa120\rtlch\afs24\lang1081\ai\ltrch\dbch\langfe1049\hich\fs24\lang1049\i\loch\fs24\lang1049\i\sbasedon1\snext9 caption;}
{\s10\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049\sbasedon1\snext10 Index;}
{\*\cs12\cf2\ul\ulc0\rtlch\afs24\lang1081\ltrch\dbch\langfe255\hich\fs24\lang255\loch\fs24\lang255 Internet link;}
{\*\cs13\cf2\ul\ulc0\rtlch\af1\afs24\lang255\ltrch\dbch\af1\langfe255\hich\f1\fs24\lang255\loch\f1\fs24\lang255 Internet link;}
}
{\info{\creatim\yr0\mo0\dy0\hr0\min0}{\revtim\yr0\mo0\dy0\hr0\min0}{\printim\yr0\mo0\dy0\hr0\min0}{\comment StarWriter}{\vern3200}}\deftab720
{\*\pgdsctbl
{\pgdsc0\pgdscuse195\pgwsxn12240\pghsxn15840\marglsxn1800\margrsxn1800\margtsxn1440\margbsxn1440\pgdscnxt0 Standard;}}
{\*\pgdscno0}\paperh15840\paperw12240\margl1800\margr1800\margt1440\margb1440\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn1800\margrsxn1800\margtsxn1440\margbsxn1440\ftnbj\ftnstart1\ftnrstcont\ftnnar\aenddoc\aftnrstcont\aftnstart1\aftnnrlc
\pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ab\ltrch\dbch\langfe1049\hich\f4\fs28\lang1033\b\loch\f4\fs28\lang1033\b {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b The histopathology of pulpitis}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af7\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 Acute pulpitis}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 Early changes within the pulp from the advancing carious}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 lesion involve the production of }{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b tertiary dentine}{\rtlch\ltrch\hich\b\loch\b  }{\ltrch\hich\lang1033\loch\lang1033 by the odontoblasts. Tertiary dentine, formerly known}}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 as irregular secondary dentine, contains fewer tubules}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 than primary or secondary dentine. Tertiary dentinemay be }{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b reactionary}{\ltrch\hich\lang1033\loch\lang1033 , laid down by primary odontoblasts}}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 in response to a mild stimulus, or }}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b reparative dentine}{\ltrch\hich\lang1033\loch\lang1033 ,laid down by secondary odontoblasts derived from otherpulp cells. This attempt at a barrier to the advancing}}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 lesion can be effective if the lesion progresses slowly and}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 particularly so if it arrests. However, with the advancinglesion, bacteria invade the odontoblasts and destroy the}}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 surrounding tissues. Clinically it is characterised by the}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 patient feeling pain in response to temperature changewhich lasts for the duration of the stimulus. There is normally}}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 no pain on biting or when the tooth is percussed.}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 The inflammation of the pulp is reversible if the causeis successfully treated, e.g. by the removal of the caries.}}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 As the pulpal inflammation becomes more extensive,}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 the pain experienced as a result of temperature changebecomes more severe and persists after the removal ofthe stimulus usually for several minutes or even longer.As the lesion approaches the pulp, inflamm
atoryresponses are detected in front of the advancing lesion.Once penetration of the pulp by bacteria has taken place,the inflammatory process becomes more profound.}}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 The response of the tissues to this invasion is seen clinicallyas }}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b acute pulpitis}{\ltrch\hich\lang1033\loch\lang1033 . The inflammation produces anincrease in pressure on the walls surrounding the pulpbecause of the presence of additional inflammatory cells,increased vascularity (hyperaemia) 
and the inability ofthe pulp chamber to expand to relieve the pressure causingthe typical symptoms of acute pulpitis. These are:}}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049 {\rtlch \ltrch\loch \'81\'a1 }{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 A constant, throbbing pain in the affected tooth that is}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 often made worse by reclining or lying down.}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 {\rtlch \ltrch\loch \'81\'a1 }{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0\ltrch\hich\lang1033\loch\lang1033 A lack of pain on biting unless the inflammation has}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 spread beyond the confines of the pulp.}
\par \pard\plain \ltrpar\s1\sl276\slmult1\sa200\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 {\rtlch \ltrch\loch \'81\'a1 }{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0\ltrch\hich\lang1033\loch\lang1033 The inability to obtain relief from the pain.}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 Other processes which can lead to bacteria penetrating}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 the pulp are trauma, e.g. a fractured tooth or traumaticexposure during cavity preparation (iatrogenic), toothwear, via the periodontal membrane or, rarely, via a bacteraemia,e.g. induced by a tooth xt
raction from anothersite (}{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b anachoresis}{\ltrch\hich\lang1033\loch\lang1033 ).}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af7\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 Chronic pulpitis}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 Chronic pulpitis may be the result of persistent mild to}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 moderate irritation of the pulp or it may follow a periodof acute pulpitis. The symptoms are:}}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049 {\rtlch \ltrch\loch \'81\'a1 }{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 A mild intermittent pain over an extended period}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 of time.}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 {\rtlch \ltrch\loch \'81\'a1 }{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0\ltrch\hich\lang1033\loch\lang1033 Pain of varying intensity.}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049 {\rtlch \ltrch\loch \'81\'a1 }{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 Pain which is often difficult to localise.}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049 {\rtlch \ltrch\loch \'81\'a1 }{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 Pain usually induced by thermal change or sweet}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 liquids or solids.}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 Symptoms may be relieved by taking analgesics which}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 act on the central nervous system (}}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 Patients have been known to try to alleviate the symptoms}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 by placing an analgesic tablet, e.g. aspirin, adjacentto the suspected tooth. Aspirin has no analgesic affect}}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 locally and is likely to compound the discomfort by}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 inducing a mucosal burn because of the high local concentrationof acetylsalicylic acid.}}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 The result of bacterial invasion is an influx of antiinflammatory}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 cells (macrophages) into the pulp and anincrease in lymphocytes and plasma cells. This producesdead bacteria, other necrotic debris and sometimesdiscrete areas of calcification including pul
p stones.}}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 The ratio of dead to living cells increases and can lead}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0  {\ltrch\hich\lang1033\loch\lang1033 eventually to death of the pulp.}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ab\ltrch\dbch\langfe1049\hich\f4\fs28\lang1033\b\loch\f4\fs28\lang1033\b {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b Abscess formation}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af7\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 Acute abscess}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 Once the pulp dies the pulpal space is invaded by bacteria which progress to the apical tissues. Early changes involve localised tissue response to the bacteria and their}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 by-products. Unless the carious lesion is large and associated with extensive tissue breakdown, the only exit pathway for necrotic tissue in the pulp is through the apical}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 foramen and into the supporting bone. The potential exists for this to increase to produce an area which contains  predominantly dead cells from the bacteria, bone and inflammatory cells. Accumulation of these cells in an enclosed space produces greater ti
ssue destruction and the formation of }}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b pus}{\ltrch\hich\lang1033\loch\lang1033 , a liquid containing large numbers}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 of polymorphonuclear cells, necrotic tissue and bacterial toxins. The pus increases in amount until tissue expansion  results in a breakout, usually along the line of least}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 resistance into the soft tissues, either via the periodontal ligament or directly into the mouth. It may also spread into the soft tissues to create a }}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b cellulitis}{\ltrch\hich\lang1033\loch\lang1033 . Such spread can}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 be dictated by the related anatomical structures. Infection via fascial planes can be rapid and extend some distance from the original abscess site, occasionally resulting in}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 occlusion of the airway by oedema, e.g. }}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b Ludwig\'81\'66s angina}{\ltrch\hich\lang1033\loch\lang1033 . Rarely it may also spread into the deeper medullary space of the alveolar bone producing a spreading }{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b osteomyelitis}{\ltrch\hich\lang1033\loch\lang1033 .}}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 There can also be an indirect spread of infection, either via the }}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b lymphatics }{\ltrch\hich\lang1033\loch\lang1033 to the regional lymph nodes in thehead and neck (the submental, submandibular, deep cervical,}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 parotid or occipital), which can become enlarged and tender, or more rarely, via the blood vessels to other organs, e.g. the heart or brain. The onset of an abscess is usually characterised by a severe throbbing pain, often easily localised by the patient.
 The tooth is normally very sensitive to biting and percussion because of the inflammation of the supporting structures. Due to the increase in pressure in the periapical region with a periapical abscess, the tooth is usually elevated in the socket which r
esults in increased}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 mobility and causes the patient to experience additional pain due to a premature contact on occlusion. A periapical abscess will give a negative response to electrical or}
\par \pard\plain \ltrpar\s1\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f1\fs24\lang1049\loch\f1\fs24\lang1049 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 hermal pulp testing (unlike a periodontal abscess where  the tooth can also be sensitive to biting or percussion).}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af7\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 Chronic abscess}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 When the abscess bursts through the bone into the adjacent soft tissues, there is usually an immediate reduction in the symptoms and, providing the abscess can continue}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 to maintain drainage, it will tend to go into a chronic phase which is frequently asymptomatic. In the chronic phase, a }}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b sinus }{\ltrch\hich\lang1033\loch\lang1033 links the main abscess cavity with the skin}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 or mucosal surface and allows further drainage to take place. This process can be associated with both primary and permanent teeth. In both cases the progression from}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 a carious lesion to a chronic abscess may be completely asymptomatic and visual examination will reveal a discharging sinus usually adjacent to the carious tooth. The}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 sinus drainage pathway may become blocked, resulting in an elevated lesion or }}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b gum boil }{\ltrch\hich\lang1033\loch\lang1033 at the gingival margin. As the pressure increases this will intermittently burst}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af8\langfe1049\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 {\rtlch \ltrch\loch\f4\fs28\lang1033\i0\b0 and discharge into the oral cavity. A dentoalveolar abscess is usually polymicrobial}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\ltrch\hich\lang1033\loch\lang1033 consisting of predominantly anaerobic organisms which include }}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\i\loch\lang1033\i Streptococcus sanguis}{\ltrch\hich\lang1033\loch\lang1033 , milleri-group streptococci, }{\rtlch\ltrch\hich\lang1033\i\loch\lang1033\i Actinomyces }{\ltrch\hich\lang1033\loch\lang1033 spp.}}
\par \pard\plain \ltrpar\s1\sl276\slmult1\sa200\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af9\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 
\par \pard\plain \ltrpar\s1\sa240\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049 {\rtlch \ltrch\loch      }{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b The dental pulp}}{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Dental}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  pulp is the living, soft tissue structure which resides in the coronal pulp chamber and root canals of primary and permanent teeth.\line \line Histologically, it is composed of loose connective tissue, surrounded on its periphery by a co
ntinuous layer of specialized secretory cells, the odontoblasts. Odontoblasts are unique to the }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b dental}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  pulp and are responsible for dentine deposition.\line \line Blood vessels and nerves enter the pulp through the apical foramen and occasionally through lateral or 
accessory root canals. The pulps of primary and young permanent teeth, especially those with incomplete apices, have a very rich blood supply.\line \line The most important function of the pulp is to lay down dentine which forms the basic structure of teeth, defines
 their general morphology, and provides them with mechanical strength and toughness.\line \line Dentine deposition commences many months (primary teeth) or years (permanent teeth) before tooth eruption and while the crown of a newly erupted tooth has a mature extern
al form, the pulp within still has considerable work to do in completing tooth development. Newly erupted teeth have short roots, their apices are wide and often diverging, and the dentine walls of the entire tooth are thin and relatively weak.\line \line Provided t
he pulp remains healthy, dentine deposition will continue during the posteruptive year for primary teeth. One of the key goals of paediatric dentistry is therefore to protect and preserve the pulps of teeth in a healthy state }{\rtlch\ltrch\hich\f4\fs28\i\loch\f4\fs28\i at least}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  until this critical p
hase of tooth development is complete.\line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b  Diagnosis of pulp pathosis and rationale}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line Studies in the early 1970s had shown that in over 50% of the primary molars where the loss of the marginal ridge had occurred, pulp inflammation was irreversible. Research ca
rried out recently in the Department of Paediatric Dentistry of the Leeds }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Dental}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Institute (Duggal }{\rtlch\ltrch\hich\f4\fs28\i\loch\f4\fs28\i et al}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 ., 2002), has corroborated these findings. In this study, it was shown that most teeth had pulp inflammation involving the pulp horn adjacent to the pro
ximal carious lesion, even when caries had involved less than half the marginal ridge, studied by measuring the inter-cuspal distance (bucco-lingual) involved in the carious process. This suggests that inflammation of the pulp in primary molars develops at
 an early stage of proximal carious attack and by the time most proximal caries is manifest clinically, the pulp inflammation is quite advanced. These findings have important clinical implications, the most important being that restoration carried out with
out pulp therapy in most primary molars, where proximal caries has manifest clinically with the involvement of the marginal ridge, will fail. Once the breakdown of marginal ridge is evident pulp therapy is invariably required. It also reiterates the import
ance of early diagnosis of proximal caries with the use of BW radiographs. Because of this early onset of inflammation in primary molars direct pulp capping is also contraindicated.}}
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Indirect pulp capping}}{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line In the majority of circumstances, carious lesions can and should be fully excavated before tooth restoration. A clinical dilemma is presented by a deep lesion in a vital, symptom-free tooth where complete removal of softened dentine 
on the pulpal floor is likely to result in frank exposure. The advancing front of a carious lesion contains very few cariogenic bacteria. Provided the bulk of infected overlying dentine is removed, a small amount of softened dentine may often be left in th
e deepest part of the preparation without endangering the pulp. This is the basis of indirect pulp capping.\line \line All caries is first cleared from the cavity margins with a steel round bur running at slow speed. Gentle excavation then follows on the pulpal floo
r, removing as much of the softened dentine as possible without exposing the pulp. Precisely how much dentine should be removed becomes a matter of experience and clinical judgement, although some have advocated the use of indicator dyes (e.g. 0.5% basic f
uchsin) to show when all infected dentine has been eliminated. A thin layer of setting calcium hydroxide cement is then placed on the cavity floor to destroy any remaining micro-organisms and to promote the deposition of reparative secondary dentine.\line \line In i
ts classical application, the indirect pulp cap was covered with zinc oxide-eugenol cement, and following several weeks' observation, the cavity was re-entered to remove all remaining softened dentine. More commonly, the calcium hydroxide pulp cap is simpl
y covered with a layer of hard setting cement and the tooth permanently restored at the same visit. Periodic clinical and radiographic review is then undertaken to monitor the pulp response.\line \line If, as has been discussed in the previous sections, the pulp is 
deemed to be inflamed, pulp therapy should be considered even in the absence of a clinical exposure. Direct pulp capping should not be carried out if an exposure is found on removal of caries, as placing a medicament, such as calcium hydroxide on an inflam
ed pulp will lead to failure.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b 8.8.4 The vital pulpotomy}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line Pulp therapy usually refers to two terms; pulpotomy and pulpectomy. A pulpotomy involves the coronal removal of the pulp tissue that is diagnosed to be inflamed or infected as a result of deep carie
s. This usually leaves an intact radicular pulp tissue upon which a medicament is applied before placing a coronal restoration.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Indications for a pulpotomy}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line \line There are certain conditions such as congenital heart defects, history of heart surgery where pul
potomy is not usually performed due to the risk of precipitating bacterial endocarditis. Also, in immuno-compromised (e.g. leukaemia) or deficient conditions, pulpotomy is contraindicated and extraction with the relevant essential precautions is usually pr
eferred.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b The pulpotomy technique}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Pulpotomy medicament}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line Formocresol has traditionally been used and widely recognized within the profession, as a medication that has delivered the best long-term results. A one-fifth dilution of original Buckleys formulati
on has been shown to be as effective as the full strength concentrate. Formocresol is not easily available in the United Kingdom and there have been some concerns about its toxicity, both locally and systemically. These concerns have grown recently with fo
rmaldehyde, one of the important components of formocresol linked to certain forms of cancer. Attempts have been ongoing for the last few years to find a suitable replacement and one material that has generated a lot of interest recently as a suitable alte
rnative to formocresol is ferric sulfate. Ferric sulfate has been widely used to control gingival bleeding, prior to impression taking and also in endodontics. It is an excellent haemostatic agent, forming a ferric ion-protein complex on contact with blood
, which then stops further bleeding by sealing the vessels. It has also now been shown to be as effective as formocresol in medium-and long-term studies when used in a concentration of 15.5%. This is available commercially as Astringident. The authors view
 is that ferric sulfate will emerge as the most suitable alternative to formocresol in the next few years. In light of recent evidence, ferric sulfate can be used as a suitable alternative for those concerned about the toxicity of formocresol or have diffi
culty obtaining it in the United Kingdom. However, it must be remembered that ferric sulfate has no "fixative" effect. For this reason, an accurate diagnosis of the state of the pulp tissue being left behind and on which ferric sulfate is being applied wil
l need to be made.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Key Points}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \~Ferric Sulfate is a suitable medicament for pulpotomy in primary molars when the inflammation is diagnosed to be restricted only to the coronal pulp.\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \~Though it stops bleeding at the site of amputation of the coronal pulp,
 it should be applied, almost immediately, for about 1 min.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Follow-up}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line Teeth that have undergone pulpotomy should be reviewed clinically and if possible radiographically, though the authors accept that routine radiographic follow-up is not possible in gen
eral }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b dental}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  practice. Clinically, the following criteria indicate success:\line \line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \~absence of symptoms;\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \~absence of any abscess or draining sinus;\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \~no excessive mobility or tenderness.\line \line Radiographically there should be:\line \line 1.\~Either no further bone loss in the 
furcation region or regeneration of bone in this area. }{\cf2\ul\ulc0\ltrch\hich\lang255\loch\lang255{\field{\*\fldinst HYPERLINK "http://online.statref.com/Document.aspx?FxID=124&DocID=164&QueryID=49897&SessionID=81F089PPBMCYHWBW" \\t "_top" }{\fldrslt \*\cs13\cf2\ul\ulc0\rtlch\ltrch\dbch\hich\f1\fs24\lang255\loch\f1\fs24\lang255 Figure 8.19}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28}}  (e) demonstrates good bone condition in the bifurcation region 6 months after the pulpotomy was performed.\line \line 2.\~No evidence of internal resorption. Internal resorption usually indicates chro
nic inflammation and the activity of giant cells causing resorption of the dentine. It creates few symptoms, and is usually detected as an incidental finding on radiographic examination. It should be considered as a form of irreversible pulpitis (}{\cf2\ul\ulc0\ltrch\hich\lang255\loch\lang255{\field{\*\fldinst HYPERLINK "http://online.statref.com/Document.aspx?FxID=124&DocID=167&QueryID=49897&SessionID=81F089PPBMCYHWBW" \\t "_top" }{\fldrslt \*\cs13\cf2\ul\ulc0\rtlch\ltrch\dbch\hich\f1\fs24\lang255\loch\f1\fs24\lang255 Fig. 8.22}
{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28}} ).\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Key Points}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \~Direct pulp capping has a poor prognosis in carious primary molars.\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \~Pulpotomy has a better prognosis than pulp capping.\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \~A pulpotomy should only be performed when the pulp inflammation is thought to be limited to the coronal pulp.\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \~Fer
ric sulfate (15.5%), available as Astringident is emerging as a good alternative to formocresol for use as a pulp medicament.}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af10\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049 
\par \pard\plain \ltrpar\s1\sa240\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 {\rtlch \ltrch\loch  }{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{ Management of non-vital and abscessed primary molars}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{\rtlch\ltrch\hich\lang1033\b\loch\lang1033\b \u61630\'3f}{\rtlch\ltrch\hich\b\loch\b the pulpectomy technique}\line \line Primary molars with abscesses are usually indicated for extractions. Persistent and chronic infection in primary molars can cause damage to the developing permanent tooth germs
 and such foci of infection should be removed.\line \line In some cases the non-vital primary molars  or ones with a chronic discharging sinus might need to be retained. Some of the reasons for this could be:\line \line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~orthodontic,\line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~medical, where extraction is not approp
riate, such as in severe haemophiliacs,\line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~parents refusal to accept extraction.\line \line In such cases these teeth can be retained by carrying out the {\rtlch\ltrch\hich\i\loch\i Pulpectomy}procedure. In the United Kingdom, there is reluctance among many dentists to carry out a pulpectomy as 
it is perceived to be difficult in a young child, with extraction being preferred. The authors feel that this is a misconception. This technique should be learnt by all paediatric dentists, as it can often save the child from the trauma of a GA for extract
ion of primary teeth. Pulpectomy involves accessing the root canal system of primary molars, cleaning them as best as is possible, and then using an appropriate material, usually pure zinc oxide eugenol, to obturate the root canals. Pure zinc oxide eugenol
 is preferred as it is entirely resorbable and is easily removed as the roots of the primary teeth undergo resorption. Also, if it is extruded through the apices, it gets completely resorbed by the apical tissues. Other materials such as Iodoform paste, an
d even calcium hydroxide are also sometimes used.\line \line The root canal morphology of primary molars is quite similar to that of permanent molars with either three of the four root canals present. In the lower primary molars there are always two mesial root cana
ls{\ltrch\hich\lang1033\loch\lang1033 \u61630\'3f}-buccal and mesio-lingual, with one or sometimes two distal root canals. In upper primary molars there are three root canals{\ltrch\hich\lang1033\loch\lang1033 \u61630\'3f}-buccal, disto-buccal, and palatal .\line \line {\rtlch\ltrch\hich\b\loch\b Indications for pulpectomy}\line \line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~Irreversible pulpitis involving both the coronal and radicul
ar pulp.\line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~Non-vital primary molars or incisors that need to be maintained in the arch.\line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~Abscessed primary molars.\line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~Primary molars with radiographic evidence of furcation pathology.\line \line The steps for performing a pulpectomy are shown in the flow diagram.\line \line {\ltrch\hich\lang1033\loch\lang1033 I
t's }a diagrammatic representation of the technique. In some cases where there is acute infection or persistent discharge from the root canals, it may be necessary to defer the root canal obturation to a {\rtlch\ltrch\hich\i\loch\i second visit}. In such cases a medicated cotton pledge
t, barely moistened with formocresol is sealed in the pulp chamber with either glass ionomer cement or IRM. (For those who are concerned about the safety of formocresol, Ledermix would be a suitable alternative.) In the second visit the pledget is removed 
and the pulpectomy procedure completed.\line \line {\rtlch\ltrch\hich\b\loch\b Follow-up and review}\line \line Though the pulpectomy technique carries a good prognosis, the outcome is not as good as a vital pulpotomy. Clinical follow-up augmented by one periapical radiograph on a yearly basis is require
d{\ltrch\hich\lang1033\loch\lang1033 .}The following clinical and radiographic parameters can be taken as indications of success:\line \line Clinical\line \line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~alleviation of acute symptoms;\line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~tooth free from pain and mobility.\line \line Radiographic\line \line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~improvement or no further deterioration of bone condition in the 
furcation area.\line \line {\rtlch\ltrch\hich\b\loch\b Root canal treatment of primary incisors}\line \line The technique described above can also be used to treat non-vital or abscessed primary incisors. Increasingly, parents are reluctant to have their child's upper anterior teeth extracted. In a moder
n society, where a child's self-esteem is important, it is the duty of the dentists to maintain aesthetics wherever possible. Many primary incisors with abscesses that are extracted can be retained with the help of a pulpectomy technique, and the root cana
l morphology is such that this can easily be performed , the only limiting factor being the child's co-operation. Indications for a pulpectomy in primary incisors include carious or traumatized primary incisors with pulp exposures or acute or chronic absce
sses.{\ltrch\hich\lang1033\loch\lang1033 It's}shows an example of primary central incisors treated with pulpectomy.\line \line {\rtlch\ltrch\hich\b\loch\b Key Points}\line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~A pulpectomy should be considered wherever it is essential to preserve a primary tooth that cannot be treated with other means, such as a pulpotomy.\line {\ltrch\hich\lang1033\loch\lang1033 \u61623\'3f}\~Both primary
 molars and incisors can be treated with a pulpectomy technique.}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af10\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049 
\par \pard\plain \ltrpar\s1\sl276\slmult1\sa240\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b TREATMENT OF A CHILD WITH HIGH CARIES RATE}}{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line It is absolutely true that restoration of children's teeth without adequate prevention is like replacing windows in a burning house. When presented with a child with a high caries rate, establishing a good preven
tive regime should be the first and foremost item in the treatment plan. However, it would be a folly to think that prevention alone will maintain the child in a pain free state. Restorative treatment or extraction of decayed teeth that are not suitable fo
r restoration should be planned alongside securing good prevention. Therefore, when dealing with a high caries risk child, a comprehensive visit by visit treatment plan that deals with the preventive and restorative care of the child should be established.
\line \line The type of treatment instituted for patients with rampant caries depends on the patients' and parents' motivation towards }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b dental}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  treatment, the extent of decay, and the age and co-operation of the child. Initial treatment, including temporary restoratio
ns, diet assessment, oral hygiene instruction, and home and professional fluoride treatments, should be performed before any comprehensive restorative programme commences. However, in patients presenting with acute and severe signs and symptoms of gross ca
ries, pain, abscess, sinus, or facial swelling, immediate treatment is indicated. This may involve extractions and even a general anaesthetic in a young child. It is wiser to extract all the teeth with a dubious prognosis under one general anaesthetic rath
er than have an acclimatization programme interrupted by a painful episode in the future.\line \line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 S}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 ummarizes the preventive regimens that should be employed for rampant caries in different age groups.\line \line Once rampant caries is under control, then comprehensive rest
orative treatment can be undertaken. This should aim to retain the primary dentition with the methods described in this chapter and in }{\cf2\ul\ulc0\ltrch\hich\lang255\loch\lang255{\field{\*\fldinst HYPERLINK "http://online.statref.com/Document.aspx?FxID=124&DocID=123&QueryID=49897&SessionID=81F089PPBMCYHWBW" \\t "_top" }{\fldrslt \*\cs13\cf2\ul\ulc0\rtlch\ltrch\dbch\hich\f1\fs24\lang255\loch\f1\fs24\lang255 Chapter 7}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28}} , and deliver the child pain free into adolescence and adulthood.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b 8.10 SUMMARY}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line 1.\~A full preventive programme 
must be instituted before any definitive restorations in a child with a high caries rate.\line \line 2.\~Repetitive treatment should be avoided and with careful treatment planning and choice of restorative materials long-lasting restorations can be carried out in chi
ldren.\line \line 3.\~The stainless-steel metal crown is the most durable restoration in the primary dentition for large cavities and endodontically treated teeth.\line \line 4.\~Resin-modified glass ionomers and polyacid-modified composite resins may have an increased role in 
the future in the restoration of primary teeth.\line \line 5.\~Rubber dam should be placed, if at all possible, prior to the restoration of all teeth.\line \line 6.\~Careful evaluation of the state of pulp inflammation should be carried out before the placement of proximal rest
orations in primary teeth. Wherever the pulp is deemed to be involved, pulp therapy should be carried out prior to the coronal restoration.\line \line 7.\~Formocresol is likely to be replaced with newer, safer medicaments such as Ferric Sulphate.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b  ACKNOWLEDGEMENTS}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line 
Some parts of this text have been reproduced from }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Dental}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Update, with the kind permission of George Warman Publications.\line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Conservative treatment options}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line Various techniques have a part to play in conservation of teeth with deep caries.\line \line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Indirect pulp capp
ing.\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Direct pulp capping\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Pulpotomy\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Pulpectomy\line \line When the tooth erupts its roots are incompletely formed and approximately 20-40% shorter than the mature root. It may take up to 5 years after eruption for the root to complete its formation and develop 
an apical constriction.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Key Point}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line Whenever it is thought that caries removal might result in a pulpal exposure, efforts should be made to preserve pulp vitality in order to enable normal root maturation to occur.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Indirect pulp capping}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line If it is thought t
hat exposure is likely to occur with full caries removal then sometimes it is expedient to leave caries in the deepest part of the lesion. Place a radio-opaque, biocompatible base over the remaining carious dentine to stimulate healing and repair. It is im
portant to completely remove caries from all the lateral walls of the cavity before placement of a restoration since failure to do so will result in spread of secondary caries and the need for future intervention.\line \line Traditionally operators have used calcium
 hydroxide for indirect pulp capping because it has a good success rate. Alternatives suggested include adhesive resins, and glass ionomer cements, but as yet there are no published studies looking at these techniques in permanent teeth. Whichever material
 is utilized, the crucial factor is to isolate the pulp well from the oral environment. Re-investigation of these teeth after about 6 months when the pulp has had an opportunity to lay down reparative dentine used to be recommended. However studies have fo
und that the residual carious dentine mostly re-mineralizes and hardens and caries progression does not occur in the absence of micro-leakage. Returning to the operative site, to complete caries removal increases the risk of pulp exposure, therefore the au
thors consider it wiser to perform the indirect pulp capping and definitive restoration in one appointment.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b The direct pulp cap}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line When a small exposure is encountered during cavity preparation the operator can place a direct pulp cap. The concept once agai
n is to preserve the vitality of the pulp. Calcium hydroxide has traditionally been used as the direct capping agent. Total etching and sealing with a dentine-bonding agent has been tried but this resulted in increased non-vitality, so it is now contraindi
cated. As in traumatic exposures, pulp capping has given disappointing results compared with the technique of partial pulpotomy, so should only be used if a pulpotomy cannot be performed.\line \line For all techniques in which the pulp is preserved it is important t
o assess the situation correctly before embarking on the treatment:\line \line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  There should be no history of spontaneous pain.\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  There should be no swelling, mobility, discomfort to percussion.\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  A normal periodontal appearance should be present radiographically.\line }
{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Pulp tissue should appear normal and vital.\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Cessation of bleeding from the pulp exposure site should occur with isotonic irrigation within 2 min.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Pulpotomy}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line Pulpotomies are successful in young teeth due to their increased pulpal circulation and abilit
y to repair. The procedure consists of applying rubber dam after local analgesia and then clearing all lateral margins around the exposure and the pulpal floor of any caries. The superficial layer of the exposed pulp and the surrounding dentine are excised
 to a depth of 2 mm using a high speed diamond bur. The technique is the same as the Cvek pulpotomy described in }{\cf2\ul\ulc0\ltrch\hich\lang255\loch\lang255{\field{\*\fldinst HYPERLINK "http://online.statref.com/Document.aspx?FxID=124&DocID=281&QueryID=49897&SessionID=81F089PPBMCYHWBW" \\t "_top" }{\fldrslt \*\cs13\cf2\ul\ulc0\rtlch\ltrch\dbch\hich\f1\fs24\lang255\loch\f1\fs24\lang255 Chapter 12}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28}}  for pulp exposure in traumatized teeth. Only tissue judged to be inflamed should be removed. Whether sufficient tissue has been remo
ved is ascertained by gently irrigating the remaining pulp surface with isotonic saline until bleeding stops. If bleeding does not cease easily, it is probable that the tissue is still inflamed and a further millimetre of pulp tissue is removed. Similarly 
if there is no bleeding at all then further pulp tissue should be removed until bleeding is found. After haemostasis has been obtained a soluble paste of calcium hydroxide is applied to the wound surface. It is important that there is no blood clot between
 the wound surface and the dressing as this will prevent repair and reduce the chances of success. Recently, MTA (mineral trioxide aggregate) has been proposed for pulp capping and pulpotomy dressings, but most of the published studies so far on this topic
 have been performed on animals. Hence at present calcium hydroxide, the tried and tested remedy should still be used. In order to aid repair, the clinician should apply dry sterile pellets of cotton wool carefully with modest pressure to adapt the calcium
 hydroxide medicament to the prepared cavity and remove excess water from the paste.\line \line As in pulp capping it is essential that the operator fills the cavity with a material that provides a good hermetic seal. The latter can be the final restoration as there
 is no need to re-enter the wound site. Although the presence of a dentinal bridge radiographically represents a success, its absence does not indicate failure. After a year, success is represented by a tooth where there are no signs of clinical or radiogr
aphic pathology and where the root has developed apically and thickened laterally. The pulpotomy technique has much to recommend it, }{\rtlch\ltrch\hich\f4\fs28\i\loch\f4\fs28\i viz.}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  a good success rate and continued root development. It is therefore considered the treatment of choice when there has 
been a pulp exposure in an immature permanent tooth.\line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Pulpectomy}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line Root canal therapy following pulpectomy has a poor success rate in young permanent molars. In a recent study only 36% of young root filled molar teeth were considered a success. Hence, pulpe
ctomy should be reserved only for cases exhibiting symptoms where the pulp is irreversibly damaged.}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af10\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 
\par \pard\plain \ltrpar\s1\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049 
\par \pard\plain \ltrpar\s1\sa240\ql\rtlch\afs24\lang1081\ltrch\dbch\langfe1049\hich\fs24\lang1049\loch\fs24\lang1049 {\rtlch \ltrch\loch  }{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0{ HYPOMINERALIZED, HYPOMATURE, OR HYPOPLASTIC FIRST PERMANENT MOLARS}}{\rtlch \ltrch\loch\f1\fs24\lang1049\i0\b0{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b Introduction}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line As caries has declined generally, it has become more apparent that there is another problem that commonly affects first permanent molars and incisors. Very recently this con
dition has been called 'molar-incisor hypomineralization' (MIH). This term covers a range of developmental anomalies from small white, yellow, or brown patches to extensive loss of tissue from almost the whole enamel surface. It is characterized by a very 
rapid breakdown of the enamel, which can be extremely sensitive. The breakdown may even occur in a few months while the tooth is still erupting. The difficulties of cleaning a partially erupted tooth are then compounded by the sensitivity. This produces an
 area where plaque builds up and which leads to rapid carious attack. As is always the case with first permanent molars, exfoliation of primary molars does not precede their eruption, so children and parents are often unaware of their presence and thus the
y do not seek treatment until the teeth start to cause problems.\line \line Molar-incisor hypomineralization has been defined as 'hypomineralization of systemic origin of one to four permanent molars frequently associated with affected incisors'. The expression of t
he phenomenon can vary in severity between patients but also within a mouth, so in one quadrant there may only be a small hypomineralized area, while in others almost total destruction of the occlusal surface}{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 .}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 \line \line Usually the incisors do not suffer the same b
reakdown of the surface and sensitivity as the molars. However, they do frequently cause a cosmetic defect. This can be treated as the child becomes conscious of it, either by coverage with composite (veneer) or partial removal of the defect and coverage w
ith composite (localized composite restoration).\line \line The first problem to remedy in molars is the sensitivity. Various desensitizing agents theoretically and anecdotally do help, but no clinical trials specifically related to MIH have been reported. They incl
ude:\line \line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Repeated application of 5% sodium fluoride varnish (Duraphat).\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Commercially available 'sensitive tooth toothpastes'.\line }{\rtlch\ltrch\hich\f4\fs28\lang1033\loch\f4\fs28\lang1033 \u61623\'3f}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  Daily use of 0.4% stannous fluoride gels.\line \line Fissure sealants can be useful where the affected areas are small and the enamel is 
intact. The use of bonding agents as described above under the resin sealant should help with bonding if the margin of the sealant is left on an area of hypomineralized enamel. The application of the bonding agents alone, once polymerized may reduce the se
nsitivity in the affected teeth }{\rtlch\ltrch\hich\f4\fs28\i\loch\f4\fs28\i per se}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28 . It is important to remember to monitor fissure sealants in these teeth very carefully as there is a high chance of marginal breakdown. If there is surface breakdown the tooth will require some form of restoration. Th
e first decision to make is whether the clinician needs to maintain the tooth throughout life or if it is more pragmatic to consider extraction . If the decision is that the first molars will be extracted as part of a long-term orthodontic plan, it is prob
able that they will still need temporisation because of the high level of sensitivity. These teeth are very difficult to anaesthetize, often staying sensitive when the operator has given normal levels of analgesic agent. If a child complains during treatme
nt of a hypomineralized molar tooth, credibility should be given to their grievance. If a child experiences pain or discomfort during treatment, they will become increasingly anxious in successive treatments. This has been shown to be true for 9-year-old c
hildren, where }{\rtlch\ltrch\hich\f4\fs28\b\loch\f4\fs28\b dental}{\rtlch\ltrch\hich\f4\fs28\loch\f4\fs28  fear, anxiety, and behaviour management were far more common in those children with severely hypomineralized first permanent molars when compared with unaffected controls.\line \line Inevitably, a balance has to be made between using simpler me
thods, such as dressing with a glass ionomer cement that may well need replenishment often on several occasions before the optimum time for extraction, and deciding early within the treatment to provide a full coverage restoration, for example. a stainless
-steel crown which should last without requiring replacement prior to extraction time. All adjuncts to help the analgesia, such as inhalation sedation should be used, if indicated. It is also useful to use rubber dam for all the usual reasons plus the prot
ection afforded by exclusion of spray from the other three un-anaesthetized molars, which probably will also be very sensitive.\line \line If the intention is to maintain the molar in the long term, then the choice of restorative techniques expands. If the area of b
reakdown of the hypomineralized enamel is relatively confined then the operator should use conventional restorative techniques. It is however difficult to determine where the margins of a preparation should be left as sometimes seemingly normal enamel (to 
visual examination) undergoes breakdown.\line \line Amalgam is of limited use, because, further breakdown often occurs at the margins, and it is non-adhesive so does not restore the strength of the tooth. Composite resins, on the other hand, when used with an approp
riate bonding agent in well, demarcated lesions, should have a good success rate. Deciding where to leave the margin in these teeth presents difficulty. Fayle (2003) described his approach of investigating abnormal looking enamel at the margins of the defe
ct with a slow rotating steel bur extending into these areas until good resistance is detected. This approach is at present not backed up by clinical studies but is a technique adopted by many dentists and could help avoid unnecessary sacrifice of sound ti
ssue. \line \line Most hypomineralized molars with surface breakdown involving one cusp or more will need a restoration with greater coverage. Either stainless-steel crowns or cast adhesive copings provide the most satisfactory options.}}
\par \pard\plain \ltrpar\s1\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\af10\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 
\par \pard\plain \ltrpar\s1\sa240\ql\rtlch\af4\afs28\lang1081\ltrch\dbch\langfe1049\hich\f4\fs28\lang1049\loch\f4\fs28\lang1049 {\rtlch \ltrch\loch  }{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0{ Preformed metal crowns (stainless-steel crowns)}}{\rtlch \ltrch\loch\f4\fs28\lang1049\i0\b0 \line \line The advantages of these are:\line \line 1. Single visit for placement.\line \line 2. Relatively quick and simple procedure.\line \line 3. Usually reduce sensitivity totally, because they cover the whole tooth.\line \line 4. Inexpensive compared w
ith cast restorations.\line \line 5. Good retention rate.\line \line The disadvantages are:\line \line 1. Require more tooth preparation than cast preparations.\line \line 2. Once a tooth has been prepared for a stainless-steel crown, it will need a full coverage restoration eventually. It has b
een suggested that placing orthodontic separators 1 or 2 weeks prior to preparation reduces the amount of tissue requiring removal. However, some reduction is usually necessary.\line \line 3. Gingival margins are sub-gingival.\line \line {\rtlch\ltrch\hich\b\loch\b Operative technique}\line \line 1.\~Obtain adequat
e anaesthesia.\line \line 2.\~Isolate the tooth to be crowned.\line \line 3.\~Select the crown size.\line \line 4.\~Remove any carious dentine and enamel.\line \line 5.\~Replace tooth bulk with glass ionomer.\line \line 6.\~Reduce the occlusion minimally.\line \line 7.\~Reduce the mesial and distal surfaces, slicing with
 a fine tapered bur. Depending on the natural anatomy of the tooth it may be necessary to create a peripheral chamfer on the buccal and lingual surfaces.\line \line 8.\~Try the selected crown; adjust the shape cervically, such that the margins extend ~1 mm below the 
gingival crest evenly around the whole of the perimeter of the crown. Sharp Bee Bee scissors usually achieve this most easily, followed by crimping pliers to contour the edge to give spring and grip. Permanent molar preformed metal crowns need this because
 they are not shaped accurately cervically. This is because there is such a variation in crown length of the first permanent molars.\line \line 9.\~After the contouring, smooth and polish the crown to ensure that it does not attract excessive amounts of plaque.\line \line 10.\~
After test fitting of the crown remove the rubber dam to check the occlusion then re-apply for cementation.\line \line 11.\~Cement the crown usually with a glass ionomer based cement.\line \line 12.\~Remove excess cement carefully with an explorer and knotted floss. Finally rec
heck the occlusion.}
\par }