Treatment for Children

8/3/2019 Treatment for Children

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Endodontic Treatment

For Children


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Aims of Endodontic Therapy

Removal of infection and chronic

inflammation.

Relief of associated pain.

Maintenance of arch length. Important for good masticatory function.

Future eruption of the permanent dentition.


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Pre-operative Assessment

General health of the child,i.e; medical

conditions.

Attitude of the parent and child. Overall assessment of the mouth.

Assessment of individual tooth. Can the tooth be restored if pulp therapy can be performed?

Does the dental age of the child warrant retention of the

particular tooth?

Is the pulp status amenable to pulp therapy?


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Difficulties in Paediatric

EndodonticsApart from limited cooperation:

1.Unable to give accurate details of their symptoms.

2. Responses to clinical tests may be unreliable.

3. In primary teeth: Molars have fine tapered roots.

Accessary canals in the furcational area.

Close proximity of the developing permanent tooth germ.

4. In young permanent teeth: Open apex.


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Type of Endodontic Treatment

Important factors which determine the type

of endodontic treatment:

1. Vitalityvital or non-vital

2. Apexopen or closed

3. Exposuretraumatic or carious


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Primary Teeth

Try to avoid premature extraction of primary teeth:

A. To allow the child to eat, speak, smile and grow with them.

B. To prevent limitations of the child diet choices.

C. To prevent exaggeration of any crowding tendencies.

D. Successfully pulp treated primary tooth is a perfect space

maintainer.

Pulp therapy for primary and young permanent teeth has

historically been subject to change and controversy.


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Diagnosis of Pulpal Pathology


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Diagnostic Features

Pain

Swelling

Mobility

Percussion

Vitality tests

Radiographs

Depth of the lesion

The exposure site

The amputated pulp stumps


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Radiographs

Before starting pulp therapy, one must have a recent radiograph. Pulp pathology takes some time to evident on radiograph.

Pulp Calcifications Associated with pulpal degeneration.

Tooth to be treated as non-vital.

Internal Resorption Buccal or lingual resorption may pass undetected.

Associated with spontaneous pain. Tooth to be treated as non-vital.

Would indicate failure if occurs after pulp capping or pulpotomy.

External Root Resorption Pathological external root resorption indicative of a non-vital pulp.

Associated with periapical radiolucency.

Treatment is pulpectomy or extraction.

Bone Resorption Radiolucency on radiograph.

If extensive, extraction.


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Internal Root Resorption


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External Root Resorption


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Treatment techniques(Primary Teeth)

Pulp capping

Indirect pulp capping Direct pulp capping

Pulpotomy Vital pulpotomy techniques

Using calcium hydroxide

Using tissue fixing medicaments

Formocresol

Glutaraldehyde

N2

Devitalizing paste

Non-vital pulpotomy techniqueor Two-visit disinfectin pulpotomy

or Mortal pulpotomy

Pulpectomy

(of non-vital teeth)


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PULP CAPPING

Indirect pulp capping

Direct pulp capping


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Indirect Pulp CappingSuccess rate 76-99%

Indications Deep asymptomatic lesion. Neglected mouths with numerous cavities.


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Advantages

Decay process arrested or slowed down

gives the pulp chance to repair.

Bacterial content of the mouth is remarkablyreduced.

Gives time for preventive programme and theassessment of patient response.

Mouth is restored to function and the threat ofdental pain reduced.

Pulp exposure is avoided.


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Contra-indications

Spontaneous painpain at night

Swelling

Fistula

Tenderness to percussion

Pathological mobility

External root resorption

Internal root resorption

Periapical or inter-radicular radiolucency

Pulp calcifications


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Technique of Indirect Pulp

Capping


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Direct Pulp Capping

Indications1. Mechanical exposures less than 1sq mm

surrounded by clean dentine in asymptomaticvital primary teeth.

2. Mechanical or carious exposures less than 1sqmm in asymptomatic vital young permanent

teeth.


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Contra-indications Spontaneous painpain at night

Swelling Fistula



External root resorption Internal root resorption


Pulp calcifications

Mechanical exposures where an instrument has beenpushed inadvertently into the pulp

Profuse haemorrhage from the exposure site

Pus or exudates at the exposure site or very largeexposure


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Technique of Direct Pulp

Capping


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Complications

Slow onset of pulpal necrosis requiringfurther endodontic treatment.


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Avoid direct pulp capping in

primary teethBecause:1. The ideal conditions demanded for success will rarely

occur.

2. The application of calcium hydroxide directly to the

pulps of primary teeth generally initiates a process of

internal resorption.

3. The alternate formocresol pulpotomy enjoys a high rate

of success.


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PulpotomyThe removal of coronal pulp and

treatment of radicular pulp.

Vital Pulpotomy

The removal of vital

(inflamed) coronal pulp

tissue, and placement of a

dressing (medicament)

over the cut radicular

pulp stumps to promote

healing or fixation oftissue in the canals.

Non-vital Pulpotomy

The removal of non-vital

(infected) coronal pulptissue and treatment of

the non-vital pulp tissue

in the canals

Pharmacologically.


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Vital Pulpotomy techniques


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Calcium Hydroxide Pulpotomy

Success rate 50-64% in some studies while inothers 12-33%


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Primary teeth with their abundant blood supply

show a more typical inflammatory response than

that seen in permanent mature teeth. The

exaggerated inflammatory response in primary

teeth account for increased internal and external

root resorption from calcium hydroxide

pulpotomies.


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Formocresol

Formalin (formaldehyde) 37% 19ml

Tricresol (cresol) 35ml

Glycerin 25ml

Water 21ml


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Single-visit Formocresol

Pulpotomy

Success rate 98%

Indications Carious or mechanical exposures in vital

primary teeth.


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Contra-indications

Spontaneous painpain at night Swelling

Fistula



External root resorption

Internal root resorption


Pulp calcifications

Pathological external root resorption

Pus or serous exudate at the exposure site

Uncontrollable haemorrhage from the amputated pulp

stumps


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Technique

Open pulp chamber

Remove pulp from pulp chamber

Arrest haemorrhage

Apply formocresol to pulp stumps

on pledget of cotton wool for 5 min

Place zinc-oxide eugenol paste in the

floor of the pulp chamber

Give lining

Restore the tooth


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Variations in Technique

Time of formocresol application Dilution of formocresol

Omission of formocresol from sub-base


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Concerns Regarding

Formocresol

Local toxicity

Systemic toxicity

Carcinogenicity and mutagenicity


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Diagrammatic Representation of

Completed Pulpotomy

Amalgam

Cement

Zinc-oxide Eugenol Paste

Vital pulp


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Glutaraldehyde Pulpotomy

Suggested by S-Gravenmade in 1975Success rate about 96%


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Advantages

Equally effective

More effective tissue fixation of the

coronal portion

More vital tissue remaining in the apical

portion of the canal

No dystrophic pulp calcifications


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Disadvantage

The solution shelf-life is only one week,


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N2 PulpotomyOne- stage pulpotomy procedure

Success rate claimed 98%


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Two-visit Devitalizing Pulpotomy

(Hobson 1970)

Indications

Where it is not possible to obtain satisfactory

anaesthesia of an exposed vital pulp or the child

does not accept local anaesthesia readily.

Where, following amputation of the coronal pulp, theradicular stumps continue to bleed excessively.

When the time factor or lack of cooperation from the childmake it difficult to complete a single-visit pulpotomyprocedure.

When an exposure is encountered at the end of a long visit on

a young child, who is becoming restless.


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Contra-indications

Prolonged bouts of spontaneous pain.

Evidence of periapical infection.

Abscess or sinus.

Wide open apices that may allow the

medicament to escape.


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Technique

First visitPlace devitalizing paste

over the exposed site

Fill the cavity for 7-10 days

Second visit

Remove devitalized coronal pulp

Wash pulp chamber thoroughly

Rest of the procedure same


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Non-vital Pulpotomy

or

Two-visit Disinfection Pulpotomyor

Mortal PulpotomySuccess rate about 66%

Indications Inability to arrest haemorrhage from the amputated

pulp stumps during a single-visit formocresol

pulpotomy. Pus at the exposure site or in the coronal pulp

chamber.

Non-vital coronal and/or radicular pulp.


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Pre-operative conditions reducing the

chances of success

Internal root resorption.

External pathological root resorption.

Gross bone loss at the apex or at the

furcation.

Pus in the pulp chamber.

Pathological mobility.

Cellulitis.


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Technique of Non-vital Pulpotomy

First visitOpen pulp chamber &remove

infected coronal pulp

Irrigate the chamber

Place cotton pellet moistened

with Beechwood cresote

in the chamber

Seal for 7-10 days

Second visitOpen the tooth (symptomless)

Remove the cotton pellet

Place zinc-oxide eugenol pasteover the floor of the pulp

chamber

Give cement lining

Restore the tooth


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PULPECTOMYFor partially vital or non-vital teeth

(usually a two stage procedure)

Controversy Regarding Pulpectomy in

Primary Teeth

Main Objections Difficulty in preparation of root canals because of complex

and variable morphology.

Uncertainty related to the effects of instrumentation,

medicaments and root canal filling material on developing

permanent teeth.

Resorption of root may not always be seen on radiograph

(two dimensional).


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Follow-up of a Pulp Treated Primary

Tooth

Clinical examinationevery 6 monthsRadiographic examinationevery 12-18 months

Clinical evidence of failure: Pain

Swelling Presence of a fistula


Radiographic evidence of failure: Increase in size of radiolucency especially bone loss at

furcation.

External or internal root resorption.

Enamel hypoplasia or arrested development of permanenttooth germ.

Inflammatory follicular cyst.


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ENDODONTIC TREATMENTFOR YOUNG PERMANENT

TEETHPulp may be exposed by

Caries

Trauma

Accidental exposure duringcavity preparation


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Choices of Treatmentprocedures

Pulp capping.

Indirect pulp capping

Direct pulp capping

Apexogenesis (vital pulpotomy).

Apexification (Induction of root end repair).


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Pulp Capping(already discussed)


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Apexogenesis(vital Pulpotomy)

It is the amputation of the coronal pulp

and treatment of the vital pulp stumpswith calcium hydroxide.

Aim:

To permit normal apical closure.


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Indications

Young permanent teeth with large exposures (where

direct pulp capping is not possible).

Where the infection or inflammation is confined to the

pulp chamber only.


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Contra-indications

Clinical or radiographic evidence of periapical infection.

Persistent haemorrhage from the amputated pulp stumps.

Non-vital pulp.

Pus in the root canals.


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Technique of Apexogenesis

Open the pulp chamber widely

Remove pulp completely

Arrest haemorrhage

Apply calcium hydroxide to

the pulp stump(s)

Give cement lining

Restore the tooth


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Follow-up

Calcific tissue forms within 68 weeks

The tooth should be kept under radiographicreview at 6 monthly, then yearly, intervals.

Once the apex is closed, conventional root

canal therapy is carried out.


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Complications

Rarely, pulpal necrosis and

apical infection occur.


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Partial pulpotomy

A ifi ti


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Apexification

(Induced apical closure)Treatment options for non-vital permanent

tooth with open apices (blunderbuss canal): Root canal therapy followed by apical surgery.

Induction of root-end repair followed by conventional root canaltherapy.

First choice not recommended because: Surgical techniques are to be avoided whenever possible in young

children.

Very difficult to do retrograde filling as the thin apical walls do notlend themselves to undercutting.

Apical surgery further reduce the length of the root which is alreadyshort because of its incomplete formation.

Therefore induction of root-end repair (apexification) is

a preferred procedure in non-vital permanent teeth with

open apices.


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Indication

An immature permanent tooth, usually an

incisor, with an infected root canal and an

incompletely formed apex, where it is

considered important to avoid extraction.


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Contra-indications

Medical reasons for avoiding root canal therapy.

Clinical and radiographic evidence of gross

apical infection and bone loss.


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Procedure for Apexification

Open the tooth & remove necrotic

tissue from the canal

Take working length radiograph & file

the canal 1-2 mm short of the apex

Irrigate &dry the canal

Fill the canal with calcium hydroxide

Seal the canal


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Calcium Hydroxide Replacement

F ll


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Follow-up

Post-operative follow up at 4 - 6 monthlyintervals include:

An evaluation of signs and symptoms.

A periapical radiograph for comparison

with the baseline radiograph.

Two types of apical closure may occur:

Root growth (cells of epithelial sheath of Hertwig alive).

Calcific tissue may form at the apex (osteodentine or

cementum).


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Follow-up(continues)

Calcific repair completion take 618 months


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Failure

Chances of failure will be more if:

Adjacent tooth is involved.

Gross bone resorption at apical area.

Inefficient procedure.

During reopening of the canal for calcium hydroxide replacement,your file can damage the partially formed calcific barrier.

If the root is very short and wide.


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Mineral Trioxide AggregateTorabinejad, 1993

A relatively new material: Alkaline pH

Biocompatible

Prevent bacterial leakage

Effective in moist environment

Uses: Pulp capping

Root end repair (Apexification)

Perforations


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Modified Formocresol Pulpotomy

Th k Y


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Thank You

Treatment for Children

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