PEDIATRIC ENDODONTICS
Dr.Bilal Arjumand
MIHS
Sequelae of Premature loss of primary teeth
Loss of arch length
Insufficient space for erupting permanent teeth
Ectopic eruption and impaction of premolars
Mesial tipping of molar teeth adjacent to primary
molar loss
Extrusion of opposing permanent teeth
Shift of the midline with a possibility of crossbite
Development of certain abnormal tongue positions
DIFFERENCES IN PRIMARY AND PERMANENT TOOTH MORPHOLOGY
Primary teeth are smaller in all dimensions than corresponding permanent teeth.
Primary crowns are wider in the mesial-to-distal dimension in comparison to their crown length than are permanent crowns.
Primary teeth have narrower and longer roots in comparison with crown length and width in permanent teeth.
The facial and lingual cervical thirds of the crowns of anterior, primary teeth are much more prominent than those of permanent teeth.
Primary teeth are markedly more constricted at the
dentin and enamel junction (DEJ) than are permanent teeth.
The facial and lingual surfaces of primary molars converge occlusally so that the occlusal surface is much narrower in the faciolingual than the cervical width.
The roots of primary molars are comparatively more
slender and longer than the roots of permanent molars.
The roots of primary molars flare out nearer the cervix
and more at the apex than do the roots of permanent
molars.
The enamel is thinner, about 1 mm, on primary teeth
than it is on permanent teeth, and it has a more consistent depth.
The thickness of the dentin between the pulp chambers
and the enamel in primary teeth is less than that in permanent teeth.
The pulp chambers in primary teeth are comparatively
larger than those in permanent teeth.
The pulp horns, especially the mesial horns, are higher
in primary molars than they are in permanent molars.
MANAGEMENT OF DEEP CARIOUS LESIONS
AND PULP INFLAMMATION IN PRIMARY
AND YOUNG PERMANENT TEETH
Determination of Pulp Status
1. Visual and tactile examination of carious dentin and associated periodontium
2. Radiographic examination of
a. periradicular and furcation areas
b. pulp canals
c. periodontal space
d. developing succedaneous teeth
3. History of spontaneous unprovoked pain
4. Pain from percussion
Determination of Pulp Status cont…………
5. Pain from mastication
6. Degree of mobility
7. Palpation of surrounding soft tissues
8. Size, appearance, and amount of hemorrhage associated
with pulp exposures
PEDIATRIC PULP THERAPY FOR PRIMARY AND YOUNG PERMANENT
TEETH
1. Indirect pulp capping
2. Direct pulp capping
3. Coronal pulpotomy
4. Pulpectomy
VITAL PULPAL THERAPY
Indirect Pulp Therapy
DIRECT PULP CAPPING AND PULPOTOMY
NONVITAL PULP THERAPY ON PRIMARY TEETH
Pulpectomy in Primary Teeth
PULPAL THERAPY FOR THE YOUNG,
PERMANENT DENTITION
Pulpotomy
The Cvek Pulpotomy on Young,Immature, Permanent Teeth
Apexification
Apexogenisis
VITAL PULPAL THERAPY
Indirect Pulp Therapy
Avoiding pulp exposure in the treatment of teeth with deep carious lesions
There exists no clinical evidence of pulpal degeneration or periapical disease
Objective is to arrest the carious process by promoting dentinal sclerosis and stimulating
promotion of reparative dentin with remineralization
of the carious dentin while preserving pulpal vitality
Infected dentin is removed, the affected dentin can remineralize and the odontoblasts form reparative dentin, thus avoiding a pulp exposure
Indirect Pulp Therapy Technique
Careful diagnosis of the pulpal status
The tooth is anesthetized and isolated with a rubber dam
eliminate all the caries at the DEJ using large, round bur or careful use of excavator
Use of caries indicator to avoid exposure (infected)
Sedative filling of either ZOE or calcium hydroxide is placed over the remaining carious dentin and
areas of deep excavation
The tooth is then sealed externally with a hard-setting ZOE (e.g., IRM), or amalgam may be placed or composite only if CaOH is used as cap.
Two-Appointment Technique (First Sitting).
Remove the majority of soft, necrotic, infected dentin with a large round bur in a slow-speed handpiece without exposing the pulp.
Cover the remaining affected dentin with a hard-setting calcium hydroxide dressing
base the remainder of the cavity with a reinforced
ZOE cement (IRM
Do not disturb this sealed cavity for 6 to 8 weeks
Two-Appointment Technique
(Second Sitting, 6 to8 Weeks Later)
If the tooth has been asymptomatic, bitewing radiograph taken, LA given, dam applied, careful removal of temporary filling
The remaining affected carious dentin should
appear dehydrated and “flaky” and should be easily
removed
After irrigation and drying, Cover the entire floor with a hard-setting calcium hydroxide dressing.
Base should be placed with a reinforced ZOE or
glass ionomer cement
One-Appointment Technique
re-entry and re-excavation
second entry subjects the pulp to potential risk of exposure owing to overzealous re-excavation
Decrease of bacteria in deep carious lesions after being covered with calcium hydroxide, so re-entry to remove the residual minimal carious dentin after capping with calcium hydroxide may not be necessary if the final restoration maintains a seal and the tooth is asymptomatic.
one-appointment indirect pulp capping must be based on clinical judgment and experience
The medicament choice for indirect pulp capping
ZOE because of its sealing and obtundant properties, which reduce pulp symptoms
Calcium hydroxide because of its ability to stimulate a more rapid formation of reparative dentin light-cured calcium hydroxide compounds were equally effective
DIRECT PULP CAPPING
DIRECT PULP CAPPING cont…
Direct pulp capping involves the placement of a biocompatible agent on healthy pulp tissue that has been inadvertently exposed from caries excavation or traumatic injury
Treatment objective is to seal the pulp against bacterial leakage, encourage the pulp to wall off the exposure site by initiating a dentin bridge, and maintain the vitality of the underlying pulp tissue regions
Case Selection for direct pulp. Cap
coronal and radicular pulp being healthy and free from bacterial invasion
appearance of the exposed pulp tissue,
Radiographic assessment, and
diagnostic tests to determine pulpal status.
Indications
rule out signs of irreversible pulp inflammation and degeneration
classic indication for direct pulp capping has been for “pinpoint”
mechanical exposures that are surrounded with sound dentin
hemorrhage that is easily controlled with dry cotton pellets
size of the exposure
Contraindications
(1) spontaneous and nocturnal toothaches, (2) excessive tooth mobility,
(3) thickening of the periodontal ligament,
(4) radiographic evidence of furcal or periradicular degeneration,
(5) uncontrollable hemorrhage at the
time of exposure, and
(6) purulent or serous exudate from the exposure
Clinical Success?
Clinical signs of successful direct pulpcapping
treatment (with or without bridging) are ;
(1) maintenance of pulp vitality,
(2) absence of sensitivity or pain,
(3) minimal pulp inflammatory responses,
(4) absence of radiographic signs of dystrophic changes
Treatment Considerations
Débridement
Debris can impede healing, therefore, remove peripheral masses of carious dentin before beginning the excavation where an exposure may occur.
When an exposure occurs, the area should be appropriately irrigated with nonirritating solutions such as normal saline to keep the pulp moist
Hemorrhage and Clotting
It can be controlled with cotton pellet pressure. A blood clot must not be allowed to form after the cessation of hemorrhage from the exposure site as it will impede pulpal healing.The capping material must directly contact pulp tissue to exert a reparative dentin bridge response. Hemolysis of erythrocytes results in an excess of hemosiderin and inflammatory cellular infiltrate, which prolongs pulpal healing
Bacterial Contamination
The success of pulp-capping procedures is dependent on prevention of microleakage by an adequate seal
Medications and Materials
Calcium Hydroxide ; produces coagulation necrosis at the contact surface of the pulp.
The underlying tissue then differentiates into odontoblasts, which elaborate a matrix in about 4 weeks.This results in the formation of a reparative dentin bridge, caused by the irritating quality of the highly alkaline calcium hydroxide, which has a pH of 11 to 12.
Dentin bridging effects of calcium hydroxide occur only when the agent is in direct contact with healthy pulp tissue
Calcium hydroxide has significant antibacterial properties helpful for pulp capping
For improving the hardness of a cavity lining material, light-cured calcium hydroxide pulp-capping products were introduced
Zinc Oxide–Eugenol Cement
ZOE more beneficial for inflamed, exposed pulps and production of a calcific bridge is not necessary if the pulp is free of inflammation following treatment.
Formocresol
exposed primary molars when capped with a paste of one-fifth diluted formocresol mixed with a ZOE paste and covered with a reinforced ZOE cement
Can be used as direct capping agent
Hybridizing Bonding Agents
Polycarboxylate Cements.
Corticosteroids and Antibiotics
Mineral trioxide aggregate (MTA)
PULPOTOMY
Pulpotomy is defined as the surgical removal of the entire coronal pulp presumed to be partially or totally inflamed and quite possibly
infected, leaving intact the vital radicular pulp within the canals
procedure is done to promote healing and retention of the vital radicular pulp.
Dentin bridging may occur as a treatment outcome of this procedure
Indications
Indicated for cariously exposed primary teeth when their retention is more advantageous than extraction
Pulpotomy candidates should demonstrate clinical and radiographic signs of radicular pulp vitality, absence of pathologic change, restorability, and at least two-thirds remaining root length.
Pulpotomized teeth should receive stainless steel crowns as final restorations to avoid potential coronal fracture at the cervical region.
Pulpotomy is also recommended for young permanent teeth with incompletely formed apices and cariously exposed pulps that give evidence of extensive coronal tissue inflammation
Contraindications
(1) root resorption exceeds more than one-third
of the root length;
(2) the tooth crown is nonrestorable;
(3) highly viscous, sluggish, or absent hemorrhage is observed at the radicular canal orifices
(4) marked tenderness to percussion
(5) mobility with locally aggravated gingivitis associated with partial or total radicular pulp necrosis exists
(6) Radiolucency exists in the furcal or periradicular areas. Persistent toothaches and coronal pus should also be considered contraindications
Three categories of treatment
approaches (Primary Teeth)
- Devitalization was the first approach to be
used with the intention of “mummifying” the
Radicular pulp tissue.
The term “mummified” has been ascribed to
chemically treated pulp tissue that is inert,
sterilized, metabolically suppressed, and
incapable of autolysis.
This approach involved the original two-sitting
formocresol pulpotomy, which resulted in
complete devitalization of the radicular pulp
2. The preservation approach
Medicaments and techniques that provide minimal insult to the orifice tissue and maintain the vitality and normal histologicappearance of the entire radicular pulp
Pharmacotherapeutic agents included in this category are corticosteroids, glutaraldehyde, and ferric sulfate.
Nonpharmacotherapeutic techniques in this category include electrosurgical and laser
pulpotomies
3. Theregenerationapproach
Pulpotomy agents that have cell-inductive capacity to either replace lost cells or induce existent cells to differentiate into hard tissue–forming elements
Calcium hydroxide was the first medicament to be used in a “regenerative” capacity because of its ability to stimulate hard tissue barrier formation
Examples of true cell-inductive agents include transforming growth factor-β (TGF-β) in the form of bone morphogenetic proteins,freeze-dried bone and MTA
Formocresol Pulpotomy
formocresol, consists of tricresol,19% aqueous formaldehyde, glycerine, and water
Fixation of the tissue directly under the medicament was apparent.
After a 7-to 14-day application, the pulps developed three distinctive zones:
(1) a broad eosinophilic zone of fixation,
(2) a broad pale-staining zone with poor cellular definition, and
(3) a zone of inflammation diffusing apically into normal pulp tissue.
After 60 days, the remaining tissue was believed to
be completely fixed
A 5-minute application resulted in surface fixation of normal tissue
An application sealed in for 3 days produced calcific degeneration.
So formocresol pulpotomy in primary pulp therapy may be classified as either vital or nonvital, depending on the duration of the formocresol application
An alternative procedure is to incorporate diluted formocresol into the ZOE dressing and then place it on the pulpal stumps
One-Appointment Pulpotomy
1. Anesthetize the tooth and tissue.
2. Isolate the tooth to be treated with a rubber dam.
3. Excavate all caries.
4. Remove the dentin roof of the pulp chamber with a high-speed fissure bur
5. Remove all coronal pulp tissue with a slow-speed No. 6 or 8 round buror Sharp spoon
excavators can remove residual tissue remnants.
6. Achieve hemostasis with dry cotton pellets under pressure.
7. Apply diluted formocresol to the pulp on a cotton pellet for 3 to 5 minutes
8. Place a ZOE cement base without incorporation of formocresol
9. Restore the tooth with a stainless steel crown.
Two-Appointment Pulpotomy.
Indications.
The two-appointment technique is indicated if there is
(1) evidence of sluggish or profuse bleeding at the amputation site,
(2) difficult-to-control bleeding,
(3) slight purulence in the chamber but none at the amputation site,
(4) thickening of the periodontal ligament, or (5) a history of spontaneous pain without
other contraindications.
A, Exposure of pulp by roof removal.
B, Coronal pulp amputation with a round bur. Hemostasis with dry cotton or epinephrine.
C, Application of formocresol for 1 minute. Excess medicament is expressed from cotton before placement.
D, Following formocresol removal, zinc oxide–eugenol base and stainless steel crown are placed
Contraindications
This technique should not be done for teeth that are ;
(1) nonrestorable,
(2) soon to be exfoliated, or
(3) necrotic.
Procedure.
1. The steps are the same as for the one-appointment procedure through step 6.
2. A cotton pellet moistened with diluted formocresol is sealed into the chamber for 5 to 7 days with a durable temporary cement.
3. At the second visit, the temporary filling and cotton pellet are removed and the chamber is irrigated with hydrogen peroxide.
4. A ZOE cement base is placed.
5. The tooth is restored with a stainless steel crown.
Calcium-Hydroxide Pulpotomy
ZoE and CaOH are used to promote healing under pulp
CaOH predictably forms bridge and maintains vitality
Available in paste form, powder mixed with sterile water etc
Calcium hydroxide is the recommended pulpotomy agent for carious and traumatic exposures in young permanent teeth
Three identifiablehistologic zones under thecalcium hydroxide in4 to 9 days:
(1) coagulation necrosis,
(2) deep-staining basophilic areas with varied osteodentin, and
(3) Relatively normal pulp tissue, slightly hyperemic, underlying an odontoblastic layer.
Indications
Pulpally involved young permanent teeth in which root apex is not complete so the procedure would allow apexogensis
Permanent Tooth Pulpotomy: Procedure
1. Anesthetize the tooth to be treated and isolate under a rubber dam.
2. Excavate all caries and establish a cavity outline.
3. Irrigate the cavity with water and lightly dry with cotton pellets.
4. Remove the roof of the pulp chamber with a high-speed fissure bur.
5. Amputate the coronal pulp with a large low-speed round bur or a high-speed diamond stone with a light touch.
6. Control hemorrhage with a cotton pellet applied with pressure or a damp pellet of hydrogen peroxide.
7. Place a calcium hydroxide mixture over the radicular pulp stumps at the canal orifices and dry with a cotton pellet.
8. Place quick-setting ZOE cement or resin-reinforced glass ionomer cement over the calcium hydroxide to seal and fill the chamber.
9. If the crown is severely weakened by decay, a stainless steel crown rather than an amalgam restoration should be used to prevent cusp fractures
NONVITAL PULP THERAPY IN PRIMARY TEETH: PULPECTOMY
The treatment objectives in nonvital pulp therapy for primary teeth are to
(1) maintain the tooth free of infection,
(2) biomechanically cleanse and obturate the
root canals,
(3) promote physiologic root resorption, and (4) hold the space for the erupting permanent
tooth
treatment of choice to achieve these objectives is pulpectomy, which involves the removal of necrotic pulp tissue followed by filling the root canals with a resorbable cement.
Indications for this procedure include teeth with poor chance of vital pulp treatment success, strategic importance with respect to
space maintenance, absence of severe root resorption, absence of surrounding bone loss from infection, and expectation of restorability
Alternative Pulpectomy Canal Obturants
Zinc oxide–eugenol
Kri paste, an iodoform compound
Partial Pulpectomy
Partial pulpectomy can be considered an extension of the pulpotomy procedure in that the coronal portion of the radicular pulp is amputated, leaving vital tissue in the canal that is assumed to be health
After successful hemorrhage control from the
amputated radicular pulp, a formocresol-dampened cotton pellet, squeezed dry, is placed in the pulp chamber for 1 to 5 minutes
The pellet is removed, and a nonreinforced fast-setting ZOE cement is packed with
pressure into the chamber and canals
Pulpotomy for Nonvital
Primary Teeth
for treating irreversibly inflamed primary
teeth, usually involving the formocresol pulpotomy technique
ALTERNATIVES TO FORMOCRESOL
Glutaraldehyde
1)it is a bifunctional reagent, which allows it to form strong intra- and intermolecular protein bonds, leading to superior fixation by cross-linkage;
(2) its diffusibility is limited;
(3) it is an excellent antimicrobial agent;
(4) it causes less necrosis of pulpal tissue
(5) it causes less dystrophic calcification in pulp canals.
Astringents
aluminum chloride
Ferric sulfate
Cell-Inductive Agents
Mineral trioxide aggregate and
calcium phosphate cement
Hydroxyapatite
Bone morphogenetic proteins
Nonpharmacotherapeutic Pulpotomy Techniques:
Controlled Energy
(1) quick and efficient,
(2) self-limiting,
(3) good hemostasis,
(4) good visibility of the field,
(5) no systemic effects, and
(6) sterilization at the site of application
Electrosurgery
Lasers