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ENDODONTIC
TREATMENT FOR THEPRIMARY TEETH
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The successful treatment of the pulpally involved tooth is toretain that tooth in a healthy condition so it may fulfill its role asa useful component of the primary and young permanentdentition.
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Premature loss of primary teeth from dental cariesand infection may result in the following sequela
Loss of arch length
Insufficient space for erupting permanent teeth Ectopic eruption and impaction of premolars
Mesial tipping of molar teeth adjacent toprimarymolar loss
Extrusion of opposing permanent teeth
Shift of the midline with a possibility of crossbite
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It is for this reason that maximum attemptsmust be made to preserve primary teeth in ahealthy state until normal exfoliation occurs.
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The basic differences between the primary and thepermanent teeth are these:
1. Primary teeth are smaller in all dimensions than the
corresponding permanent teeth.2. Primary crowns are wider from mesial to distal in
comparison to their crown length than arepermanent crowns.
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3. Primary teeth have narrower and longer roots incomparison to crown length and width than dopermanent teeth.
4. Primary teeth are markedly more constricted at the
dentin-enamel junction than are permanent teeth.
5. The facial and lingual surfaces of primary molarsconverge occlusally so the occlusal surface is muchnarrower in the facial-lingual than the cervical width.
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6. The roots of primary molars flare out nearer the cervix,and they flare more at the apex, than do the rootsof permanent molars.
7. The enamel is thinner, about I mm, on primary teeththan on permanent teeth and it has a more consistentdepth.8. The thickness of the dentin between the pulp chambers and
the enamel in primary teeth is less than in permanent teeth.
9.. The pulp chambers in primary teeth are comparativelylarger than in permanent teeth.10. The pulp horns, especially the mesial horns, are higher in
primary molars than in permanent molars.
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A suggested outline for determining the pulpal statusof cariously involved teeth in children involves thefollowing:
Visual and tactile examination of carious dentin andassociated periodontiumRadiographic examination of
a. periradicular and furcation areasb. pulp canalsc. periodontal spaced. developing succedaneous teeth
. History of spontaneous unprovoked pain
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Pain from percussion
Pain from mastication
Degree of mobility
Palpation of surrounding soft tissues Size, appearance, and amount of hemorrhage
associated with pulp exposures
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Pulp therapy for primary and young permanentteeth involves the following techniques:
1. Indirect pulp capping
2. Direct pulp capping
3. Coronal pulpotomy
4. Pulpectomy
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This approach has gained increased worldwidepopularity in recent years.
Rationale:
To arrest the carious process and provide conditionsconducive to the formation of reactionary dentin
To promote pulpal healing and preserve the vitality ofpulp tissue
Indications: Tooth with a deep carious lesion
No signs or symptoms indicative of pulpal pathosis
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Procedure: Local anesthesia Good isolation with rubber dam
Removal of all caries at the enamel-dentinejunction
Judicious removal of soft deep carious dentine
Placement of appropriate lining material . Definitive restoration to achieve optimum external
coronal seal (ideally an adhesive restoration or
preformed crown)
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This approach has limited application and is generallynot recommended for primary molars.
Rationale:
To encourage the formation of a dentine bridge at thepoint of pulpal exposure with preservation of pulpalhealth and vitality
Indications:
Asymptomatic tooth Small traumatic (non-carious) pulpal exposure
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Procedure: Local anesthesia
Optimum isolation with rubber dam
Gentle application of cotton pledget soaked inwater/saline to stem any pulpal haemorrhage
Application of hard-setting calcium hydroxidepaste or mineral trioxide aggregate (MTA)
Definitive restoration
Clinical outcome:
Prognosis is reported to be generally poor.
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is the the surgical removal of the entire coronalpulp presumed to be partially or totally
inflamed and quite possibly infected, leavingintact the vital radicular pulp within the canals.
A germicidal medicament is then placed overthe remaining vital radicular pulp stumps at
their point of communication with the floor ofthe coronal pulp chamber.
A restoration is placed over the remaining vitalpulp
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Rationale:
To remove the coronal pulp, which has beenclinically diagnosed as irreversibly inflamed,
leaving behind a possibly healthy or reversiblyinflamed radicular pulp
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Vital pulpotomy Indications
Asymptomatic tooth or only transient pain
A carious or mechanical exposure of vital
coronal pulp tissue
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Contraindications: a nonrestorable tooth, tooth nearing exfoliation or with no bone
overlying the permanent tooth crown, a history of spontaneous toothache, evidence of periapical or furcal pathology, a pulp that does not hemorrhage, inability to control hemorrhage following a
coronal pulp amputation, a pulp with serous drainage the presence of a fistula
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Procedure:
Local anesthesia
Good isolation with rubber dam
Removal of caries
Complete removal of roof of pulp chamberwith a non-end cutting bur
Removal of coronal pulpal tissue with sharpsterile excavator or large round bur in a slowhandpiece
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Attain initial radicular pulpal haemostasis bygentle application of sterile cotton pledgetmoistened with saline (haemostasis should beachieved within four minutes)
Selection of medicament for direct application toradicular pulp stumps to include any of thefollowing:
15.5% ferric sulphate solution
20% (1:5 dilution) Buckleys formocresol solutionapplied to radicular pulp on a cotton pledget forfive minutes to achieve superficial tissue fixation
MTA paste applied over radicular pulp
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Application of a lining (if appropriate) such asreinforced glass ionomer or zinc oxide eugenolcement
Definitive restoration to achieve optimumexternal coronal seal (ideally an adhesiverestoration of preformed metal crown)
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Contraindications:
nonrestorable teeth
soon to be exfoliated
necrotic.
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Procedure:
The steps are the same as for the one-appointmentprocedure.
A cotton pellet moistened with dilutedformocresol is sealed into the chamber for 5 to 7days with a durable temporary cement.
At the second visit, the temporary filling andcotton pellet are removed and the chamber isirrigated with hydrogen peroxide.
A ZOE cement base is placed.
The tooth is restored with a stainless steel crown
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Rationale:
To reduce pulpal inflammation and/orsymptoms in order to facilitate subsequent
pulpotomy or Pulpectomy procedure Indications:
Non-compliant child who may require
inhalation sedation for further treatment Hyperalgesic pulp (adequate analgesia not
achieved)
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Procedure: Local anesthesia Good isolation with rubber dam Removal of caries Place a small pledget of cotton wool loaded with
steroidal antibiotic paste (LedermixTM) directly overexposure site (tooth is usually too sensitive to removeentire roof of pulp chamber)
Place a well-sealed temporary dressing (IRM -without
undue pressure) over the cotton pledget Recall after 714 days and proceed with a pulpotomy
or Pulpectomy technique (depending on clinicalfindings)
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It means complete removal of the pulp from atooth, that is irreversibly infected or necrotic dueto caries or trauma.
Rationale
To remove irreversibly inflamed or necroticradicular pulp tissue and gently clean the rootcanal system
To obturate the root canals with a filling material
that will resorb at the same rate as the primarytooth and be eliminated rapidly if accidentallyextruded through the apex
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Indications:
Radicular pulp exhibiting clinical signs ofhyperemia such as excessive hemorrhage.
Necrotic pulp with minimum tooth resorption. Traumatized primary incisors in children
under (5years.)
Primary teeth with furcal or periapicalpathology
Presence of abscess
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Contraindications:
Non-restorable crown.
Extreme mobility. Advanced internal and external root
resorption.
Extensive bone resorption
Perforated pulpal floor
Primary teeth with underlying dentigerouscyst or granuloma.
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Problems of root canal morphology.
Possibility of damage to permanentsuccessor
Difficult to maintain hermetic seal because ofphysiologic root resorption.
Resorbable root canal filling
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A one- or two-stage Pulpectomy may beundertaken depending on whether the radicularpulp is irreversibly inflamed or non-vital(with/without an associated periradicular
pathosis). If infection is present, and the presence of an
exudates does not allow drying of the canal,consideration should be given to the two-stage
Pulpectomy technique, where the root canals maybe dressed with an antimicrobial agent for 710days and subsequently obturated at the secondvisit.
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Pre-operative radiograph showing all roots and
their apices
Local anesthesia
Rubber dam isolation Removal of caries
Removal of roof of pulp chamber preferably with
non-end cutting bur
Removal of any remains of coronal pulp tissuewith sharp sterile excavator or large bur in slow
handpiece
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Note whether radicular pulp is bleeding (one-stage procedure) or necrotic (usually requiringtwo-stage procedure)
Identify root canals Irrigate with normal saline (0.9%),
Chlorhexidine solution (0.4%) or sodiumhypochlorite solution (0.1%)
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Estimate working lengths of root canalskeeping 2-3 mm short of the radiographic apex
Insert small files (no greater than size 30) into
canals and file canal walls lightly and gently Irrigate the root canals
Dry canals with pre-measured paper points,
keeping 2 mm from root apices
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If infection present (canal exudates and/orassociated sinus) dress root canals with non-settingcalcium hydroxide and temporize (two-stageprocedure)
If canals can be dried with paper points, obturate
root canals by injecting or packing a resorbable pastee.g. slow-setting pure zinc oxide eugenol,
paste or Iodoform paste Definitive restoration to achieve optimum external
coronal seal (ideally a preformed crown)
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Clinical outcome
86% clinical success at 36 months follow up(lower success rates found at longer follow-up
times
Review
clinical and radiographic review following anyprimary molar pulp therapy is mandatory
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