ENDODONTIC TREATMENT FOR THE PRIMARY TEETH

The

successful treatment of the pulpally involved tooth is to retain that tooth in a healthy condition so it may fulfill its role as a useful component of the primary and young permanent dentition.

Premature loss of primary teeth from dental caries and 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 to primarymolar loss Extrusion of opposing permanent teeth Shift of the midline with a possibility of crossbite

It is for this reason that maximum attempts must be made to preserve primary teeth in a healthy state until normal exfoliation occurs.

The basic differences between the primary and the permanent 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 are permanent crowns.

3. Primary teeth have narrower and longer roots in comparison to crown length and width than do permanent 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 molars converge occlusally so the occlusal surface is much narrower in the facial-lingual than the cervical width.

6. The roots of primary molars flare out nearer the cervix, and they flare more at the apex, than do the roots of permanent molars. 7. The enamel is thinner, about I mm, on primary teeth than on permanent teeth and it has a more consistent depth. 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 comparatively larger than in permanent teeth. 10. The pulp horns, especially the mesial horns, are higher in primary molars than in permanent molars.

A suggested outline for determining the pulpal status of cariously involved teeth in children involves the following: Visual and tactile examination of carious dentin and

associated periodontium

Radiographic examination of a. periradicular and furcation areas b. pulp canals c. periodontal space d. developing succedaneous teeth . History of spontaneous unprovoked pain

Pain from percussion Pain from mastication Degree of mobility Palpation of surrounding soft tissues Size, appearance, and amount of hemorrhage associated with pulp exposures

Pulp therapy for primary and young permanent teeth involves the following techniques: 1. Indirect pulp capping 2. Direct pulp capping 3. Coronal pulpotomy 4. Pulpectomy

This approach has gained increased worldwide popularity in recent years. Rationale: To arrest the carious process and provide conditions conducive to the formation of reactionary dentin To promote pulpal healing and preserve the vitality of pulp tissue Indications: Tooth with a deep carious lesion No signs or symptoms indicative of pulpal pathosis

Procedure:

Local anesthesia

Good isolation with rubber dam Removal of all caries at the enamel-dentine junction 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)

This approach has limited application and is generally not recommended for primary molars. Rationale: To encourage the formation of a dentine bridge at the point of pulpal exposure with preservation of pulpal health and vitality Indications: Asymptomatic tooth Small traumatic (non-carious) pulpal exposure

Procedure:

Local anesthesia Optimum isolation with rubber dam Gentle application of cotton pledget soaked in water/saline to stem any pulpal haemorrhage Application of hard-setting calcium hydroxide paste or mineral trioxide aggregate (MTA) Definitive restoration Clinical outcome: Prognosis is reported to be generally poor.

is the 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. A germicidal medicament is then placed over the remaining vital radicular pulp stumps at their point of communication with the floor of the coronal pulp chamber. A restoration is placed over the remaining vital pulp

Rationale:

To remove the coronal pulp, which has been clinically diagnosed as irreversibly inflamed, leaving behind a possibly healthy or reversibly inflamed radicular pulp

Vital pulpotomy Indications Asymptomatic tooth or only transient pain A carious or mechanical exposure of vital coronal pulp tissue

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

Procedure: Local anesthesia Good isolation with rubber dam Removal of caries Complete removal of roof of pulp chamber with a non-end cutting bur Removal of coronal pulpal tissue with sharp sterile excavator or large round bur in a slow handpiece

Attain initial radicular pulpal haemostasis by gentle application of sterile cotton pledget moistened with saline (haemostasis should be achieved within four minutes) Selection of medicament for direct application to radicular pulp stumps to include any of the following: 15.5% ferric sulphate solution 20% (1:5 dilution) Buckleys formocresol solution applied to radicular pulp on a cotton pledget for five minutes to achieve superficial tissue fixation MTA paste applied over radicular pulp

Application of a lining (if appropriate) such as reinforced glass ionomer or zinc oxide eugenol cement Definitive restoration to achieve optimum external coronal seal (ideally an adhesive restoration of preformed metal crown)

Indications. Evidence of sluggish or profuse bleeding at the amputation site, difficult-to-control bleeding, thickening of the periodontal ligament, or a history of spontaneous pain without other contraindications

Contraindications: nonrestorable teeth soon to be exfoliated necrotic.

Procedure:

The steps are the same as for the one-appointment procedure. A cotton pellet moistened with diluted formocresol is sealed into the chamber for 5 to 7 days with a durable temporary cement. At the second visit, the temporary filling and cotton pellet are removed and the chamber is irrigated with hydrogen peroxide. A ZOE cement base is placed. The tooth is restored with a stainless steel crown

Rationale: To reduce pulpal inflammation and/or symptoms 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)

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 over exposure site (tooth is usually too sensitive to remove entire 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 clinical findings)

It means complete removal of the pulp from a tooth, that is irreversibly infected or necrotic due to caries or trauma. Rationale To remove irreversibly inflamed or necrotic radicular pulp tissue and gently clean the root canal system To obturate the root canals with a filling material that will resorb at the same rate as the primary tooth and be eliminated rapidly if accidentally extruded through the apex

Indications: Radicular pulp exhibiting clinical signs of hyperemia such as excessive hemorrhage. Necrotic pulp with minimum tooth resorption. Traumatized primary incisors in children under (5years.) Primary teeth with furcal or periapical pathology Presence of abscess

Contraindications:

Non-restorable crown. Extreme mobility. Advanced internal and external root resorption. Extensive bone resorption Perforated pulpal floor Primary teeth with underlying dentigerous cyst or granuloma.

Objectives:

The radiographic infectious process should resolve in 6 months, as evidenced by bone deposition in the pretreatment radiolucent areas Pretreatment clinical signs and symptoms should resolve within a few weeks. The treatment should permit resorption of the primary tooth root and filling material to permit normal eruption of the succedaneous tooth. There should be no pathologic root resorption or furcation/apical radiolucency.

Problems of root canal morphology.

Possibility of damage to permanent successor

Difficult to maintain hermetic seal because of physiologic root resorption. Resorbable root canal filling

A one- or two-stage Pulpectomy may be undertaken depending on whether the radicular pulp 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 may be dressed with an antimicrobial agent for 710 days and subsequently obturated at the second visit.

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 tissue with sharp sterile excavator or large bur in slow handpiece

Note whether radicular pulp is bleeding (onestage procedure) or necrotic (usually requiring two-stage procedure) Identify root canals Irrigate with normal saline (0.9%), Chlorhexidine solution (0.4%) or sodium hypochlorite solution (0.1%)

Estimate working lengths of root canals keeping 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

If infection present (canal exudates and/or associated sinus) dress root canals with non-setting calcium hydroxide and temporize (two-stage procedure) If canals can be dried with paper points, obturate root canals by injecting or packing a resorbable paste e.g. slow-setting pure zinc oxide eugenol, paste or Iodoform paste Definitive restoration to achieve optimum external coronal seal (ideally a preformed crown)

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 any primary molar pulp therapy is mandatory