Pedodontics Lectures

6,7, 8,9
presented by Dr Marwa Salman BDS, MSc, DMD
Pediatric Pulpal Therapy
Preservation of the dental arch and its functions are the
main motives behind pediatric dentistry. Retention of
primary teeth are needed until natural exfoliation occurs.
Advantages of restoring the pediatric dentition:
1. Maintenance of arch length and tooth space.
2. Maintenance or aesthetics.
3. Prevention of infection.
4. Elimination of pain
5. Restoring the ability to chew and gain nutrition
6. prevention of speech abnormalities and abnormal habits.
7. Aids in timely eruption of permanent teeth.
 Pediatric Pulpal Therapy
Pulp exposures caused by caries occur more frequently
in primary teeth then in permanent teeth because
primary teeth have relatively large pulps chambers,
more prominent pulp horns, and thinner Enamel and
Dentin. Although is has been established that the pulp is
capable of healing, there is still much to learn about the
control of infection and inflammation in the vital pulp.
Pediatric Pulpal Therapy
Diagnostic aids in the selection of teeth for vital
pulp therapy:
1. History of pain
2. clinical signs and symptoms
3. Radiographic interpretation
4. Pulp testing
5. Physical condition of the patient.
 Pediatric Pulpal Therapy
1. History of Pain:
-The history of either the presence or absence of
pain may not be as reliable in the primary
dentition as it is in the permanent dentition.
Degeneration of the primary pulp to the point of
access formation without the child recalling pain
or discomfort is not uncommon.
-History of a toothache should be the first
consideration the selection of teeth for vital tooth
therapy.
-A toothache coinciding with or immediately after
a meal may not mean extensive pulpal
inflammation but may rather be caused by an
accumulation of food within the carious lesion, by
pressure, or by thermal and chemical irritation to
the pulp protected by a thin layer of intact dentin.
 Pediatric Pulpal Therapy
1. History of Pain:
A severe toothache at night usually
means extensive degeneration of the
pulp and calls for more than a
conservative type of pulpal therapy.
A spontaneous toothache of more than
momentary duration occurring at any
time, means pulpal disease progressed
too far for vital pulp treatment
 Pediatric Pulpal Therapy
2. Clinical signs and symptoms:
A gingival abscess or draining fistula associated with a
tooth with a deep carious lesion is an obvious sign of an
irreversibly diseased pulp, such infection can be
resolved only by successful endodontic therapy or
extraction of the tooth.
Abnormal tooth mobility is another clinical sign that may
indicate a severely diseased pulp.
If pain is absent or minimal during the manipulation of
the diseased mobile tooth the pulp is probably in a more
advanced and chronic degenerative condition.
Pathological mobility must be distinguished from normal
mobility in primary teeth near exfoliation.
Also tooth mobility or sensitivity to percussion or
pressure may be a sign of high restoration or
advanced periodontal disease.
 Pediatric Pulpal Therapy
3. Radiographic Interpretation:
A recent radiograph must be available to examine and evaluate the
periradicular or periodical changes, such as thickening of the
periodontal ligaments or rarefaction of the supporting bone.
Radiographic interpretation in children is more difficult than in adults.
The permanent teeth may have incomplete roots end forming giving
an impression of a periapical radiolucency.
The roots of primary teeth may be undergoing normal physiological
resorption often presenting a misleading picture suggestive of
pathological changes.
 Pediatric Pulpal Therapy
The proximity of caries to the pulp cannot be determined
accurately by an x-ray image. what may appear to be an
intact barrier of secondary dentin protecting the pulp may
actually be a perforated mass of irregularly calcified and
carious material, with the pulp beneath it being extensively
inflamed.
Calcified bodies in the pulpal tissue are an indication of
chronic inflammation. Radiographically they appear as
radiographic bodies in the pulp chamber.
Pediatric Pulpal Therapy
4. Pulp testing:
The value of pulp testing in primary teeth is
questionable. this test does not give reliable evidence
of degree of inflammation of the pulp.
The reliability of the pulp test for the young child can
also be questioned sometimes because of the child’s
apprehension associated with the test itself.
Pediatric Pulpal Therapy
5. Physical condition of the patient:
In the case of seriously ill children, extraction of the involved
tooth after proper premedication with antibiotics, rather than
pulp therapy, should be the treatment of choice.
Children with conditions that render them susceptible to
subacute bacterial endocarditis, or those with nephritis,
leukaemia, solid tumors, or any immune compromised
conditions or medication should not be subjected to the
possibility of an acute infection resulting from failed pulp
therapy.
Pediatric Pulpal Therapy
Other factos to consider affecting the evaluation of treatment prognosis before
pulpal therapy :
1. The level of patient and parent cooperation and motivation in receiving treatment.
2. The level of patient and parent desire and motivation in maintaining oral health and
hygiene.
3. The caries activity of the patient and the overall prognosis of oral rehabilitation.
4. The stage of dental development of the patient.
5. The degree of difficulty anticipated in adequately performing the pulp therapy for
each particular case / tooth.
6. Space management consideration resulting from extraction, preexisting mal
occlusion, ankylosis, congenital missing teeth, and space loss caused by the extensive
carious destruction of the teeth and subsequent drifting.
7. Excessive extrusion of the pulpally involved tooth resulting from missing opposing
teeth.
Pediatric Pulpal Therapy
Treatment of the deep carious lesion:
Children and young adults who have NOT received early and
adequate dental care and optimal systemic fluoride often
have deep carious lesions in the primary and permanent
teeth. Many of the lesions appear radiographically to be
dangerously close to the pulp. with many of them entering the
dental office after pulpal exposure has occurred.
Pediatric Pulpal Therapy
Indirect pulp treatment ( gross caries removal with indirect pulp
therapy )
This procedure is performed in a deep carious lesion adjacent to the
pulp, it entails the removal of gross decay or soft decay in a vital,
SYMPTOM FREE tooth, where complete removal of softened dentition
the on the pulpal floor is likely to result in a frank exposure. after
gross removal the cavity is sealed for a time with a bactericidal agent.
Indications:
1. Deep carious lesion near to pulp but not involving it.
2. No tooth mobility
3. No history of spontaneous pain.
4. No tenderness to percussion
5. No radiographic evidence of pulp pathology.
6. No radiographic evidence of root resorption or bone loss.
Pediatric Pulpal Therapy
Contraindications:
1. presence of pulpal exposure.
2. Radiographic evidence of pulp therapy.
3. History of spontaneous pain
4. tooth sensitive to percussion
5. Mobility present
6. Radiographic evidence of root resorption or radicular
disease.
Pediatric Pulpal Therapy
The clinical procedure involves :
1. Removal of the gross decay with a large round bur or a sharp spoon excavator,
allowing sufficient caries to remain of the pulp horn to avoid exposure of the pulp.
2. Use of a Local anesthesia is preferred is possible as the procedure may cause
discomfort for a child.
3. The walls of the cavity are extended to sound tooth structure with a fissure bur,
because carious enamel and dentin at the margin of the cavity will interfere with the
establishment of an adequate seal during the period of repair.
4. The remaining thin layer of caries in the base of the cavities is dried and covered
with a bactericidal dressing. ( GIC, Calcium hydroxide, theracal, …) followed by a temp
material.
5. The treated tooth should not be reentered to complete the removal of decay for at
least 6-8 weeks waiting period During this period the caries action in the deepest layers
is arrested. The rate of regular dentin formation observed during the indirect pulp
treatment was highest in the first month but continues for a year under observation.
Pediatric Pulpal Therapy
6.After the 6-8 week period The tooth is anaesthetized
and isolated with a rubber dam, and the temporary
restorative material and liner removed .
7. careful removal of the remaining carious material,
sclerotic dentin may appear around a sound base of
dentin without exposure.
8. If a secondary layer of dentin has formed covering
the pulp, a liner material containing calcium hydroxide
is applied.
9. The cavity preparation is completed, and the tooth
is restored in a conventional manner.
Pediatric Pulpal Therapy
Vital Pulp Exposure :
The health of the exposed dental pulp is difficult to determine,
especially in children, therefor the appropriate procedure should be
selected only after a careful evaluation of the patients symptom,
results of diagnostic aids, and condition of the pulp at the exposure
site.
Pediatric Pulpal Therapy
Vital pulp therapy techniques :
1. Direct Pulp Capping :
-The pulp capping procedure has been widely practiced and should be
limited to mechanical small exposure that have been accidentally
produced by trauma or during cavity preparation to true pinpoint
exposures surrounded by sound dentin.
-Its use should be limited to PERMANENT teeth due to the high
relationship to internal resorption or pulp necrosis in primary teeth,
contrary to permanent teeth with high vascular pulps in immature
permanent teeth allowing great healing capacity.
-Pulp capping should be considered only for teeth with an absence of
pain with possible exception of discomfort caused by intake of food.
Pediatric Pulpal Therapy
1. Direct Pulp Capping :
-There should be lack of bleeding at the exposure site, excessive
bleeding indicates a hyperaemic or inflamed pulp.
-All pulp treatment procedures should be carries out under clean
conditions using sterile instruments.
- All peripheral carious tissue should be excavated before beginning to
excavate the portion of the tooth most likely to result in a pulp exposure.
- Calcium Hydroxide is the material of choice for pulp capping normal
vital pulp tissue. The possibility of its stimulating the repair of dentin is
good.
- The patients parents should be advised to return if any hot cold
sensitivity arises or any unfavourable symptoms appear.
Pediatric Pulpal Therapy
2. Pulpotomy :
- The removal of the coronal portion of the pulp is an accepted procedure for
treating both primary and permanent teeth with carious pulp exposures.
- The coronal pulp tissue which is adjacent to the carious exposure usually
contains microorganisms and shows evidence of inflammation and degenerative
change.
- The abnormal tissue can be removed, and the healing can be allowed to take
place at the entrance of the pulp canal in the area of what is expected to be
normal healthy pulp.
- In the pulpotomy procedure the tooth must be first anaesthetized and isolated
with a RD.
- All remaining dental caries should be removed and the overhanging Enamel
should be planned back to provide good access to coronal pulp.
Pediatric Pulpal Therapy
- Pain during caries removal and instrumentation
may be an indication of faulty anaesthesia
technique, but most times its an indication of pulpal
hyperaemia and inflammation leading to poor
prognosis if vital pulpotomy is done. If excessive
bleeding occurs from the pulp this is also an
indication of poor prognosis. In both cases a
different treatment option should be pursued.
- The entire roof of
the pulp chamber should be removed with a bur, no
overhang dentin, or pulp horn should be left
remaining.
- A sharp spoon, large enough to extend over the
entrance of the root canals should be used to
remove the pulp. The pulp should be irrigated with a
flow of water from the water syringe and excavated.
- Moist cotton pellets should be placed over the root
stumps until a clot forms, This clot is essential for
healing.
Pediatric Pulpal Therapy
Calcium Hydroxide Pulpotomy technique ( Vital Pulpotomy) :
- This technique is recommended in the treatment of permanent teeth
with a carious exposure when there is pathological change in the pulp
at the exposure site.
- This procedure is best indicated for permanent teeth with immature
root development but with healthy pulp tissue in the root canals. Also
indicated for teeth with a pulp exposure, resulting from fracture of the
crown/ Trauma while the apex is not completely formed.
- It is completed in a single appointment.
- Only teeth that have no symptoms are considered for vital pulpotomy.
Pediatric Pulpal Therapy
Calcium Hydroxide Pulpotomy technique ( Vital Pulpotomy) :
- The procedure involves the amputation of the coronal potion of the
pulp, The control of hemorrhage, and the placement of Calcium
Hydroxide capping material over the pulp tissue remaining in the canals.
- Protective layer of a hard setting cement is placed over the Calcium
Hydroxide and the tooth is prepared for full coverage.
- If the tissue in the root canals appears hyperaemic after the amputation
of the coronal tissue, a pulpotomy should no longer be considered.
Endodontic treatment is to be completed if the tooth is to be saved.
Pediatric Pulpal Therapy
Formocresol Pulpotomy ( Fixed pulpotomy )
- Formocresol pulpotomy is recommended for primary teeth
with carious exposure because they do not respond
favourably to Calcium Hydroxide technique, as it induces
resorption in primary teeth.
- The same diagnostic criteria for selection of permanent teeth
for vital pulpotomy should be used for the selection of primary
teeth formocresol pulpotomy.
- This technique is also completed in a single appointment.
- After LA and RD isolation, the coronal portion of the pulp is
amputated, the debris removed from the chamber and the
bleeding controlled.
- If there is hyperaemic bleeding after the removal of the pulp
tissue then this technique should be abandoned in favour of
partial or complete pulpectomy or tooth removal.
Pediatric Pulpal Therapy
Formocresol Pulpotomy ( Fixed pulpotomy )
- If the bleeding is controlled and the pulp stumps appear normal it
may be assumed that the pulp tissue in the canals is normal and it is
possible to proceed with the pulpotomy.
- The pulp chamber is dried with sterile cotton pellets, then a pellet
moistened with Formocresol and blotted dry on sterile gauze to
remove excess from is placed in contact with the pulp stumps and is
allowed to remain for 5 mins ? .
*** Formo is caustic and should not contact soft tissue or skin
- If the pulp stumps turn black instead of red then then the chamber
is restored with Zinc oxide cement and the cavity is then restored
with filling material followed by an SSC.
Pediatric Pulpal Therapy
3. Partial Pulpectomy.
- A partial pulpectomy may be preformed on primary teeth when coronal pulp
tissue and the tissue entering the pulp canals is hyperaemic but still show
signs of vitality.
- The tooth may or may not have a history of pulpitis, but the contents of the
root canals should not show any evidence of necrosis. In addition there should
be no radiographic evidence of PDL widening or periradicular disease. If any
of these are present then a pulpectomy or extraction should be completed.
- It is completed in one appointment, it involves removal of the pulp from the
pulp chamber and removal of pulp filaments from the canals by using a
barbed broach, this will lead to considerable haemorrhage
Pediatric Pulpal Therapy
3. Partial Pulpectomy.
- A headstrom file is helpful in removal of the
remaining tissue, care should be taken to not reach or
go through the apex of the roots.
-After removal of tissue irrigation first with Hydrogen
Peroxide followed by Sodium hypochlorite. then the
canals are to be dried with sterile paper points.
- when all bleeding has stopped a mix of ZOE is used
and introduced into the canals with the paper points.
- A think mix of the same paste is then used to place
into the chamber and pushed into the canals using
root canal pluggers.
- The restoration is then completed and the tooth
covered with SSC.
- A follow up radiograph should be taken to show fill
of the canals with ZOE before placement of the SSC.
Pediatric Pulpal Therapy
Non Vital Therapy Techniques:
Complete pulpectomy :
Its is a liability to keep non vital untreated infected primary teeth
in the mouth. They may be opened for drainage and often remain
asymptomatic of an indefinite period of time. These teeth are a
source of infection and should be treated or extracted.
- In this technique a RD is placed and the roof of the pulp
chamber is removed in order to gain access to the canals.
content of the pulp and the coronal third of the canals should be
removed. Care must be taken to not force any of the debris
through the apical foramen of the tooth. a cotton pellet for
Formocresol is placed in the chamber and covered with ZOE.
Pediatric Pulpal Therapy
Non Vital Therapy Techniques:
Complete pulpectomy :

-After a few days this cotton pellet is removed and IF

the tooth has been asymptomatic for these days then
the same procedure for partial pulpotomy is completed.
If the tooth is painful then a small file should be allowed
to penetrate the apical foramen and the canals cleaned,
then a cotton pellet with Formo is placed again and the
treatment repeated.
Pediatric Pulpal Therapy
Apexification:
One of the most difficult endodontic problems is to
adequately fill a canal with open apex or incompletely formed
root. An open apex is found in the developing root of an
immature tooth and in the absence of pulp disease, is
Normal, However, when pulp undergoes necrosis before root
growth is completed, dentin formation ceases and root
growth is arrested.
The procedure term apexification refers as to a method of
inducing a calcified apical barrier or continued apical
development of an incompletely formed root in which the
pulp is necrotic.
Pediatric Pulpal Therapy
1, In apexification the canal is cleansed, sanitized in the routine
endodontic manner with the use of a rubber dam. The access
opening is made as usual but may require some extension
especially in the anterior teeth, in order to accommodate the
larger sized instruments necessary to clean the root canals.
2. The length of the canal is established radiographically and the
canal is cleaned as throughly as possible.
3. Frequent irrigation with Sodium hypochlorite helps remove
debris from the canal.
4. After through debridement the canal is dried and medicated
with suitable intracanal medicament. It is then sealed with
temporary cement.
** If symptoms persist or any signs of infection are present at a
subsequent appointment or if the canal cannot be dried, the
debridement phase is repeated and the canal is medicated with
a slurry of Ca(OH)2 paste and sealed.
Pediatric Pulpal Therapy
5. When the tooth is free of signs or symptoms of
infection the the canal is dried and filled with Calcium
Hydroxide preparation( Pulpdent)
. The filling procedure is usually preformed without the
use of LA. This is preferred as the patients response can
be utilized to indicate approaching the apical foramen.
After the canal is filled, the access opening must be
sealed with a permanent filling material composite resin
is recommended for anterior teeth and Ag for post teeth.
The usual time required for active apexification is 6-24
months, and apical barrier will develop, against which a
conventional Gutta Percha endodontic procedure can be
completed. During this time the tooth is recalled every 3
months to monitor the tooth.
Pediatric Pulpal Therapy
Reaction of the pulp to various capping material:
Zinc Oxide Eugenol:
Before calcium hydroxide came into use , ZOE was
used more often than any other pulp capping
material. It is considered contraindicated for direct
pulp capping because when it is in contact with vital
pulp tissue it will produce chronic inflammation,
necrosis and abscess formation.
Pediatric Pulpal Therapy
Reaction of the pulp to various capping material:
Calcium Hydroxide:
It is so caustic ( because its alkalinity PH12) that when its
placed in contact with vital pulp tissue the reaction
produces a superficial necrosis of the pulp. The
superficial necrotic area in the pulp that develops
beneath the calcium hydroxide is demarcated from the
healthy pulp tissue below by a new, deeply staining zone
comprising basophilic elements of the calcium hydroxide
dressing. Its indicated for direct and indirect pulp
capping and vital pulpotomy and other vital treatment.
Pediatric Pulpal Therapy
Preparations containing formalin :
1. Formaldehyde ( Tricresol formaline):
The use of material containing formalin gives clinical success
especially in the treatment of primary pulps. This is related to the
drug’s germicidal action and fixation quality, rather than promote
healing.
Formalin use in permanent teeth remains questionable unless a
subsequent root canal filling is done. Since 1950 , it has been
applied with great success as a primary pulp medication and
remains the most popular agent in vital primary pulp therapy today
** in the recent years there has been a shift away from formalin
containing products due to research suggesting carcinogenic
affects of the material.
Pediatric Pulpal Therapy
Glutaraldehyde:
It is an excellent bactericidal agent and seems to offer some
advantages in comparison to formocresol.

Corticosteroid :
Capping material containing corticosteroids combined with
antibiotics, although it seems to produce a clinical success BUT
when the pulp evaluated microscopically a degenerative process
happens within the pulp and inhibition of dentinigenesis.

Antibiotics :
Capping materials containing antibiotics have been used in dentistry
with considerable attention due to sensitivity reaction to certain Ab.
Pediatric Pulpal Therapy
Ferric Sulphate:
More recently, considerable interest and research have been devoted to
investigating the effectiveness of ferric sulphate to treat the surface of
the remaining pulp tissue after a pulpotomy of primary teeth. Ferric
sulphate agglutinates blood portions and controls haemorrhage in the
process without clot formation. The main advantage of ferric sulphate
over formocresol when working with kids is the faster speed with which
bleeding can be controlled and subsequently the pulpotomy
completed.
 Pediatric Pulpal Therapy
Pulpotec:
Is a radiopaque, non resorbable filling paste used for rapid
and long term treatment of pulpitis and treatments of
pulpotomies in vital molars, both permanent and primary. It is
composed of a powder ( polyoxymethylene, iodoform, and
zinc) and liquid ( dexamethasone acetate, formaldehyde,
phenol, ) . The addition of pharmacological ingredients
ensures an aseptic treatment, induces cicatrization of the
pulpal stump at the chamber canal interface, while
maintaining the structure of the the underlying pulp.
Pediatric Pulpal Therapy
MTA ( Mineral Trioxide Aggregate):
New material developed for endodontics that appears to
be a significant improvement over other materials for tissue
development procedures in bone, studies show that MTA
prevents micro leakage, is biocompatible, and promotes
regeneration of the original tissues when it is placed in
contact with the dental pulp or periradicular tissues. In
addition to its use as a pulp capping material, its indication
in apexification, repair of root resorption and perforations
during RCT, and root end fillings.
Pediatric Pulpal Therapy
take home info when studying :
- Know when we need to give LA and when not
- Know which procedures are completed on vital teeth
and which are non vital
- know which material are preferred for each procedure
- Know which are a single appointment vs multiple
appointment
- Know which procedures may be done for primary
dentition and which for permeant dentition, in addition to
temporary or final procedure