MANAGEMENT OF DEEP CARIOUS LESIONS IN

CHILDREN
Pulp exposure is caused most commonly by caries but may also occur during cavity
preparation or by fracture of the crown. Pulp exposures caused by caries occur more
frequently in primary than in permanent teeth because primary teeth have relatively large
pulp chambers, more prominent pulp horns and thinner enamel and dentine. In primary
molars with proximal cavities, pulp involvement occurs in about 85% of those with
broken marginal ridges.

Diagnostic aids in selection of teeth for vital pulp therapy

1-History of pain:
The dentist should distinguish between two types of pain: provoked and spontaneous pain
(unprovoked).
 Provoked pain: is precipitated by stimulus (thermal, chemical or mechanical) and
disappears after removal of stimulus. For example:
Pain associated with eating is due to pressure from accumulated food within the
carious lesion and chemical irritation to the vital pulp protected by a thin layer of
dentine (good prognosis).
Pain due to cold or hot food or drinks may indicate hyperemia or pulpitis.

 Spontaneous pain: is a throbbing constant pain that may keep the patient awake at
night. It indicates advanced pulp damage (poor prognosis).

2-Clinical signs and symptoms:

A. Abnormal tooth mobility indicates severely diseased pulp or involvement of
periodontal ligament.
B. Sensitivity to percussion indicates apical or periodontal inflammation or both.
C. Presence of swelling, sinus, draining fistula or chronic abscess indicates a non vital
pulp.
D. Size of exposure and amount of pulpal bleeding are the most valuable observations in
diagnosing the condition of the primary pulp:
 Small pin-point exposure surrounded by sound dentine indicates favorable
condition for vital pulp therapy.
 Large exposure with watery exudate or pus indicates unfavorable condition for
vital pulp therapy.
 Small controllable amount of bleeding during and or following pulp amputation is
a favorable condition for pulp therapy.
 Excessive uncontrollable bleeding during and or following pulp amputation is an
unfavorable condition for pulp therapy.

3-Radiographic interpretation:
Periapical and bitewings radiographs are used to examine periapical area and supporting
bone. Pulp exposure cannot be accurately detected from an x-ray film. Radiographic
interpretation in children is more difficult than adults due to:
a. Young permanent teeth with incompletely formed root ends give the impression of
periapical radiolucency.
b. The roots of primary molars undergoing normal physiologic resorption may
suggest a pathologic change.
c. Permanent teeth are superimposed on the primary teeth.

Radiographs are valuable for determining the following:

a) Periapical changes such as widening of periodontal membrane space.

b) Rarefaction in supporting bone.
c) Calcified masses within pulp chamber and root canals.
d) Periapical and interradicular radiolucencies of bone.
4-Vitality tests:
Either thermal or electrical.
Thermal pulp vitality tests:
 Application of heat (hot gutta percha or hot instrument).
 Application of cold (ethyl chloride or ice cone).
 The reaction of a normal tooth is tested first (pain on application of stimulus which
disappears after removal of stimulus).
 If pain persists, this indicates hyperemia or pulpitis.
 If tooth does not respond, this indicates a non-vital pulp.

Electric pulp tester:

 Record the reading of a normal tooth first.
 If the affected tooth responds at a lower reading than normal, this indicates
hyperemia or pulpitis.
 If the affected tooth responds at a higher reading, this indicates pulp degeneration.

Disadvantages of electric pulp tester:

a) Child may become apprehensive and gives a false positive response.

b) Pulp tester may give false positive response when content of pulp is liquid
(liquefaction necrosis).

5-Physical condition of patient:

Seriously ill children e.g. heart disease, nephritis, leukemia or tumors should not be
subjected to the possibility of an acute infection resulting from pulp therapy. 64

Moreover, the pulp might not posses normal regenerative power. Extraction of the
involved tooth after proper premedication with antibiotics is the treatment of choice in
such conditions.
 Vital Pulp Therapy
Pulp Capping
The aim of pulp capping is to maintain pulp vitality by placing a suitable dressing either
directly on the exposed pulp (direct pulp capping) or on a thin residual layer of soft
dentine at the base of the cavity (indirect pulp capping).

 Indirect Pulp Capping

Definition:
It is the procedure in which only the gross caries is removed from the lesion, while the
remaining carious dentine which if removed would result in pulp exposure is covered
with a material which promotes healing.

Indications:
Teeth with deep carious lesions approximating the pulp, free of any clinical or
radiographic signs of pulp disease.

Technique:
First visit:
1- Administer local anesthesia and isolate tooth with rubber dam.
2- Gross caries is excavated from the carious lesion, while the leathery dentine in the
deepest portion is left and covered with calcium hydroxide paste and a reinforced
temporary dressing.
3- Tooth should not be re-entered for 6-8 weeks. During that period the carious process in
the deep layer will be arrested and calcium hydroxide will stimulate the formation of
secondary dentine and the remaining microorganisms will be destroyed by bactericidal
action of calcium hydroxide.

Second visit:
The tooth is re-entered and any remaining carious dentin is carefully removed. Sound
dentin is apparent which protects the pulp. Apply calcium hydroxide dressing and restore
the tooth in usual manner. If a small exposure is encountered a different type of treatment
is provided.
N.B., Recently the need for the second visit (i.e. re-entering the tooth) is questioned.
Proper case selection and adequate sealing with a durable restorative material ensures
success. If no adverse signs or symptoms develop, there will be no need for re-entry.
By the end of pulp capping, treatment is judged successful if there is:
1- No sensitivity to percussion.
2- No history of pain following treatment.
3- No radiographic evidence of periapical pathosis or root resorption.
4- No clinical evidence of pulp exposure if the tooth was re-entered.

 Direct Pulp Capping

Definition:
It is the procedure of covering the exposed vital pulp with a material which promotes
healing.

Indications:
1) Small pinpoint exposure surrounded by sound dentin, produced accidentally during
cavity preparation or due to trauma.
2) Absence of pain with the exception of pain during eating.
3) Normal vital pulp.
4) No bleeding at exposure site or an amount that would be considered normal.
5) Normal radiographic findings.

Technique:
1- Administer local anesthesia and isolate tooth with rubber dam.
2- When pulp is exposed during the last stages of caries removal, carious dentin chips
will be pushed into the pulp tissue which becomes contaminated resulting in pulpitis.
3- So enlarging the exposure site is needed to wash away carious and non carious
fragments and allow direct contact of capping material with pulp tissues.
4- Flush the exposure site with normal saline to clean the area and keep the pulp moist
while a clot is forming.
5- Cap the pulp with calcium hydroxide followed by reinforced cement and the
permanent restoration.
N.B. Direct pulp capping is not encouraging in primary teeth because pulp tissue ages
early and less active undifferentiated mesenchymal cells are available which can be
induced to transform into odontoblasts and lay down secondary dentin. Moreover, during
process of root resorption, some cells may transform to odontoclasts causing internal
resorption

Pulpotomy
Definition:
It is the removal of coronal pulp tissue till the level of enterance of pulp canals and
capping the radicular pulp tissue to keep it in a good condition.

Indications:
1. In primary and young permanent teeth with wide pulp exposures when the tissues
adjacent to exposure site show slight evidence of inflammation.
2. Slight amount of bleeding at exposure site which is considered within normal.
3. Normal vital pulp.
4. Normal clinical and radiographic signs.

Technique:
1. Administer local anesthesia and isolate the tooth with rubber dam.
2. Establish outline form to ensure access to the pulp chamber.
3. Remove all carious dentin with round bur and spoon excavator, this ensures a clean
operating field.
4. Remove the roof of pulp chamber using a fissure bur.
5. Remove any overhanging ledges of dentin as pulp tissue under ledges may not be easy
to remove.
6. Amputate the coronal pulp tissue with a large spoon excavator or with a large round
bur in low speed handpiece carefully to avoid perforation of the floor of the pulp
chamber.
7. Wash and flush the pulp chamber with sterile water or saline solution.
8. Dry and control bleeding with sterile cotton pellets for about 4 minutes. If bleeding
continues, look for remnants of coronal pulp still adhering to the walls of the pulp
chamber and remove them.
9. Apply capping material.
Types of pulpotomy according to the capping material used:

1- Calcium Hydroxide Pulpotomy:

It is indicated in young permanent teeth with exposed vital pulp and incomplete root
formation. Under calcium hydroxide, the pulp is able to maintain its vitality; it organizes
an odontoblastic layer to lay down reparative dentin and gives the chance to the root to
complete its apical growth.
After pulpotomy is completed and formation of healthy clot a layer of Ca (OH) 2 is
applied then reinforced cement and the permanent restoration is inserted. This procedure
gives 61 % success.

2- Formocresol Pulpotomy:
It is recommended for primary teeth with carious exposure. The formocresol used is
Buckley’s formocresol which is composed of 19 % formalin and 35 % cresol in a vehicle
of glycerin and distilled water. Formocresol solution releases formaldehyde, which
diffuse through the pulp and by combining with cellular protein fixes the pulp tissues.
Formocresol, as supplied, can be diluted to 1:5 concentration using 3 parts of glycerin
and one part distilled water.
Success rates up to 96% have been reported using formocresol pulpotomy in vital
primary teeth.
There are two methods for formocresol pulpotomy:
• The one step technique (one visit technique).
• The two steps technique (2 visits techniques).

The one step technique:

1- After amputation of the coronal pulp, control of bleeding and formation of a blood
clot, apply a cotton pellet moistened with formocresol and blotted on a sterile cotton roll
to remove the excess over the radicular pulp stumps for 4-5 minutes. Pulp stumps appear
dark brown.

2- Prepare a paste of reinforced zinc oxide-eugenol .Remove the cotton pellet moistened
with formocresol and place enough paste to cover the radicular pulp stumps. Pressure
should be avoided on radicular pulp tissues.

3. Fill the pulp chamber with temporary cement and prepare the tooth for a stainless steel
crown.
The two steps technique:
If there is any sign of hyperemia following amputation of coronal pulp (pain or excessive
hemorrhage) indicating that inflammation is present in the tissues beyond the coronal
portion of the pulp, two visits formocresol pulpotomy, partial pulpectomy or even
extraction of the tooth is indicated.
1- After coronal pulp amputation, a cotton pellet moistened with formocresol is placed
over the radicular pulp stumps and covered with temporary dressing.
2- In the second visit after 2-3 days, isolate tooth with rubber dam without local
anesthesia, remove the dressing and pellet and complete the procedure as one visit
technique.

N.B.: A stainless steel crown is the ideal restoration after pulpotomy because the crown
of the tooth is brittle and may fracture.

Partial pulpectomy:
Definition:
It is the removal of coronal pulp tissue and as much as possible of the contents of root
canals without interfering deeply into the apical portion.
Indications:
1- It is indicated in primary molars as it is impractical to perform complete pulpectomy in
such teeth because of: difficulty to obtain adequate access to the root canals in the small
mouth of children and due to the complexity in morphology of root canals having lateral
branchings and apical ramifications where removal of all radicular pulp content is
impossible.

2- When the coronal and radicular pulp tissue are vital but show clinical evidence of
hyperemia .

3- The tooth may or may not have a history of pain.

4- No evidence of necrosis (tooth is vital).

5- Normal radiographic findings (no evidence of widening of periodontal membrane

space or periapical pathosis).
Technique:
The technique is completed in one appointment:
1- Remove the coronal pulp tissue (same steps in pulpotomy).
2- Remove as much as possible from the content of root canals with a serrated broach.
Care should be taken not to penetrate the apex.
3- No widening of the root canals is done.
4- Irrigation of the canals with normal saline.
5- Dry the canals with sterile paper points.
6- The root canals may be filled with zinc oxide-eugenol (a resorbable material which
will be resorbed as normal root resorption occurs).

Filling the root canals:

• A thin mix of zinc oxide-eugenol paste may be prepared and paper points covered with
the material are used to coat the root canal walls.
• A thick mix of the zinc oxide-eugenol should be prepared, rolled into a point and
carried into the root canal.
• Root canal plugger may be used to condense the material into the canal.
• Zinc phosphate is put as a base and the tooth should be restored with chrome steel
crown.

Non-vital pulp therapy

Complete pulpectomy [endodontic treatment]

Definition:
It is the complete removal of coronal and radicular pulp tissue.

Indications:
- In non-vital primary anterior teeth where the root canals are accessible.
- The canals may be prepared with the help of a radiograph. Care should be taken not to
traumatize the apical region.
- The root canals are filled with a resorbable material such as zinc oxide eugenol , or
premixed calcium hydroxide paste (vitapex) which is composed of iodoform and calcium
hydroxide
Treatment of non-vital primary molars :
Ideally a non-vital tooth should be treated by pulpectomy and root canal filling. However,
complete pulpectomy in primary molars is extremely difficult and often impractical. A
non-vital pulpotomy method is advocated.

Technique of non-vital pulpotomy:

First visit :
1- Necrotic coronal pulp tissue is removed (as pulpotomy).
2- Seal a cotton pellet moistened with formocresol or camphorated monochlorophenol
into the pulp chamber for 7-10 days. The strong antiseptic action of these materials
combats infection in radicular pulp.

Second visit:
1- Remove cotton pellet and place antiseptic paste composed of zinc oxide and eugenol.
2- Press antiseptic paste into root canals with a cotton pellet. Pressure forces the paste
down the root canals.
3- Restore the tooth in usual manner.
N.B: This technique could be used in the presence of sinus , abscess or some degree of
tooth mobility. A sinus is expected to disappear following control of infection and a
mobile tooth becomes firm as periapical bone reforms .

Reaction of the pulp to commonly used capping materials:

Pulp capping agents have developed along three main lines:
1- Devitalization.
2- Preservation.
3- Regeneration.

1- Devitalization:
This procedure is based on complete fixation of underlying radicular pulp tissue thereby
avoiding infection and internal resorption. This is achieved by using formocresol. 74
- Formocresol:
Formaldehyde in formocresol is a strong tissue fixative and has an antimicrobial action.
Tissue fixation is achieved by chemical binding of formaldehyde with proteins in pulp
cells, while its bactericidal effect is achieved by chemical binding to proteins of
microorganisms.
Histologically, formocresol produces progressive fixation of pulp tissue with ultimate
fibrosis of the entire pulp.

2- Preservation:
This procedure produces only minimal insult to underlying pulp tissue without initiating
an inductive process, thereby preserving maximum vital radicular pulp tissue. This is
achieved by using glutaraldehyde and ferric sulphate.

- Glutaraldehyde:
Similar to formaldehyde, glutaraldehyde fixes proteins of pulp cells. However, molecules
of glutaraldehyde are larger than formaldehyde which limits its penetration into the
underlying pulp tissue. Moreover, binding of glutaraldehyde to proteins of pulp cells is
stronger and irreversible.
Histologically, when glutaraldehyde is placed over vital pulp tissue it produces an initial
zone of fixation which does not migrate apically. The tissues underlying this fixed zone
have cellular details of normal pulp which suggests that the vitality of the remaining pulp
is maintained. The material is used as 2 % or 5 % buffered glutaraldehyde solution for
pulpotomy technique in primary teeth.

- Ferric sulphate:
It is a non – aldehyde chemical which is used as a 15.5 % solution for pulpotomy
technique in primary teeth based on its hemostatic and coagulative properties.
Histologically, when ferric sulphate is applied to amputated pulp tissue, blood reacts with
ferric and sulphate ions which cause agglutination of blood proteins. These agglutinated
proteins form plugs to occlude the capillary orifices which produce chemical sealing of
the cut blood vessels.
3- Regeneration:
This procedure is based on induction of reparative dentin formation by the pulp capping
agent, thereby leaving the underlying radicular pulp tissue vital and healthy. This could
be achieved by using calcium hydroxide and mineral trioxide aggregate.

- Calcium hydroxide:
It is a highly alkaline material with pH 12. It consists mainly of calcium and hydroxyl
ions. The calcium ions stimulate cellular proliferation in pulp tissue. The hydroxyl ions
maintain a state of alkalinity important for cell proliferation and produce an antiseptic
effect. It is used in pulpotomy technique in young permanent teeth.
Histologically, the pulp tissue underneath the calcium hydroxide remains vital and
organizes an odontoblastic layer to lay down reparative dentin which gives a chance for
the root to complete its apical growth.
One month after the capping procedure, a calcified bridge is evident radiographically.
This bridge increases in thickness during the next 12 months. The pulp beneath the
calcified bridge remains vital and free from inflammatory cells.

- Mineral trioxide aggregate:

A pulp capping agent with excellent sealing ability. It is highly biocompatible with potent
antimicrobial properties due to its high alkalinity (pH 12.5). The material has the ability
to stimulate dentin bridge formation adjacent to dental pulp.

N.B
Electrosurgery pulpotomy:
It is known as non – chemical devitalization. Its mechanism of action is cauterization of
pulp tissue.

Laser pulpotomy:
It produces superficial zone of coagulation necrosis which remains compatible with
underlying tissues and isolates the pulp from vigorous effects of external stimuli.
Failures following vital pulp therapy:

1-Internal resorption:
• Occurs within pulp canals several months following pulpotomy.
• It is a destructive process due to osteoclastic activity.
• Pulp canals become widened, walls become thin and perforation may occur.

Etiology:
1- A true carious pulp exposure is usually associated with some degree of
inflammation. This inflammation may be limited to coronal pulp tissue or may
extend to the entrance of pulp canals. Osteoclasts may become attracted to the area
and initiate resorption.
2- All capping materials are irritating and produce some degree of inflammation ,
inflammatory cells in the area of inflammation may attract osteoclasts which
initiate internal resorption.
3- Because the roots of primary teeth are undergoing normal physiological resorption
there is osteoclastic activity in the area which may predispose the tooth to internal
resorption.

2-Alveolar abscess:
- Develops several months following pulp therapy.
- Infection may be present in bone around root apex or more commonly in
bifurcation area.
- May be associated with fistula in chronic conditions.
- Primary teeth which develop an alveolar abscess should be removed, while
permanent teeth can be treated with endodontic treatment.

General contraindications for pulp treatment of primary teeth:

1- A patient from family having unfavorable attitude towards dental health and
conservation of the teeth.
2- A tooth, with gross breakdown that restoration would be impossible following pulp
treatment.
3- A tooth with caries penetrating the floor of pulp chamber.
4- A tooth close to natural exfoliation.
5- A patient with poor general health.
Pulp therapy for young permanent teeth

Apexogenesis [vital pulpotomy]:

Indications:
Vital permanent teeth with immature root development having large carious or traumatic
exposures. The tooth should have normal clinical and radiographic signs.
Aim:
Maintain the radicular pulp vital to allow complete root development. Calcium hydroxide
placed over radicular pulp stumps stimulates the formation of a calcific bridge and
successful root closure.

Apexification [ root end closure in non-vital teeth ]:

Indications:
In young permanent teeth with pulp necrosis and incompletely formed apices.
Aim:
To promote root elongation and or calcific root closure. Even though the pulp is necrotic ,
epithelial root sheath of Hertwig persists and allows regeneration.
Technique:
The entire pulp is removed and calcium hydroxide is used to fill the root canals and is
replaced every 3-4 months until apical closure occurs . The tooth is then treated with root
canal therapy.
 EXTRACTION OF TEETH IN CHILDREN
The general principles of oral surgery remain the same whether applied to the adults or to
children. However, there are some factors to be considered in oral surgery for children as
compared to adults:
1. The oral cavity is small and there is greater difficulty in gaining access to the field of
operation.

2. The jaws are in the process of growth and development and the dentition is in a
continuous state of change with eruption and resorption of primary teeth and eruption of
permanent teeth. Any premature extraction of primary teeth may lead to irregularities in
the permanent teeth.

3. The bone structure of a child contains higher percentage of organic material, which
makes it more pliable than adult bone and not as likely to fracture.

Indications for extraction of primary teeth:

1. Teeth decayed beyond possible repair.
2. Infection of the periapical or inter - radicular area which cannot be eradicated
by other means.
3. Acute dento - alveolar abscess with cellulitis.
4. Teeth interfering with normal eruption of succeeding permanent teeth.
5. Submerged teeth.

Contraindications to extraction of primary teeth:

Many of these contraindications are relative and may be overcomed with special
precautions and premedication.
1. Acute infectious stomatitis, acute ulcerative gingivitis or acute herpetic
gingivostomatitis. The acute phase should be controlled before extraction.
2. Blood disorders: These render the patient susceptible to postoperative infection and
hemorrhage. Extractions should be performed only after consultation with hematologist
and proper preparation of the patient.
3. Rheumatic heart disease, congenital heart disease and congenital kidney disease
require proper antibiotic coverage.
4. Acute systemic infections of childhood, because of lowered body resistance.
Malignancy, if suspected, on the other hand, extractions is strongly indicated if the
orofacial areas are to receive irradiation
5. Teeth which have remained in irradiated bone.
6. Diabetes mellitus: Extraction can be done after the condition is controlled.
Indications for extraction of permanent first molars:
- If a permanent first molar is removed before the permanent second molar has erupted
through the gingiva, the chances that the second molar will move mesially and occupy
the space of the extracted first molars are very good.
- When two first molars are diseased beyond repair, they should be removed.
- But if three first molars are diseased beyond repair, all four molars should be removed
with the expectation that a more symmetrical dentition will result.

Preoperative preparation:
As the extraction of a tooth can be emotionally upsetting to the child and the parents,
some preparations are necessary.
a) Parent’s preparation:
- A parental consent is important before extraction.
- Any possible medical condition that may require special precaution should be
discussed.

b) Child preparation:
- Avoid the use of technical words and words suggesting fear or pain.
- Explain to the child what sensation may be experienced.
- The child should realize the difference between pressure and pain.

Techniques for the removal of primary teeth:

Although extraction of a deciduous tooth with completely resorbed roots is a simple task,
removal of some of the deciduous teeth with all or part of the roots present can be
challenging.
- Armamentarium for extraction procedures is much the same as for adult, but as all
anatomic structures are smaller, special forceps are available for primary teeth.
- Fracture of a slender root is common, especially when there is uneven resorption. These
roots should be removed using a small elevator or even a large spoon excavator or
universal scaler.
- When removing young permanent teeth, the young elastic bone structures and
incomplete root development usually facilitate the extraction.
92
Extraction of anterior teeth:
Anterior teeth should be luxated to the labial during the extraction procedure due to the
lingual position of the permanent teeth buds then rotated slightly and delivered labially.

Extraction of maxillary primary molars:

- Because the palatal root is curved, it indicates the direction of the removal, and the
initial direction of force is slightly to the palatal.
- Slight force is emphasized in order not to fracture the curved palatal root then in a
single sustained force to the buccal until the tooth is loosened.
- A counterclockwise motion delivers the tooth out of the socket.

Extraction of mandibular primary molars:

- The cross-section of the mandibular first primary molar roots is flat mesiodistally and
elliptical, therefore, any rotary motion is contra- indicated.
- The initial force is slightly to the lingual; then a single sustained force to the buccal
until the tooth is loosened.
- A counterclockwise rotation delivers the tooth from the socket.
- During extraction, the mandible is supported with the non-extraction hand to protect
TMJ against any possible injury.

Postoperative instructions:
1. For the child:
1. The child should not be dismissed until a blood clot has formed, the child is instructed
to hold between his lips a small cotton roll until his lips "wake up".
2. The child may return to school or go out and play once the numbness has gone.
3. A child should be reassured that he will get a new tooth in the place of the one that was
removed.

2. For the Parents:

- Tell the parents why the cotton roll is used and that they should not be concerned if
there is slight oozing or blood from the socket.
- Light meal with no hard food is recommended.
- The parents are instructed not to continuously ask the child how painful the area is.
- Simple written instructions can be helpful.