Endodontic Treatment For Children

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.

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?

Difficulties in Paediatric Endodontics

Apart 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.

Type of Endodontic Treatment

Important factors which determine the type of endodontic treatment:
1. 2. 3. Vitality vital or non-vital Apex open or closed Exposure traumatic or carious

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.

Diagnosis of Pulpal Pathology

Diagnostic Features
Pain Swelling Mobility Percussion Vitality tests Radiographs Depth of the lesion The exposure site The amputated pulp stumps

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.

Internal Root Resorption

External Root Resorption

Treatment techniques
Pulp capping
(Primary Teeth) 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 technique

or Two-visit disinfectin pulpotomy or Mortal pulpotomy

Pulpectomy
(of non-vital teeth)

PULP CAPPING
Indirect pulp capping Direct pulp capping

Indirect Pulp Capping

Success rate 76-99%

Indications
Deep asymptomatic lesion. Neglected mouths with numerous cavities.

Advantages
Decay process arrested or slowed down gives the pulp chance to repair. Bacterial content of the mouth is remarkably reduced. Gives time for preventive programme and the assessment of patient response. Mouth is restored to function and the threat of dental pain reduced. Pulp exposure is avoided.

Contra-indications
Spontaneous pain pain at night Swelling Fistula Tenderness to percussion Pathological mobility External root resorption Internal root resorption Periapical or inter-radicular radiolucency Pulp calcifications

Technique of Indirect Pulp Capping

Direct Pulp Capping

Indications
1. Mechanical exposures less than 1sq mm surrounded by clean dentine in asymptomatic vital primary teeth. 2. Mechanical or carious exposures less than 1sq mm in asymptomatic vital young permanent teeth.

Contra-indications
Spontaneous pain pain at night Swelling Fistula Tenderness to percussion Pathological mobility External root resorption Internal root resorption Periapical or inter-radicular radiolucency Pulp calcifications Mechanical exposures where an instrument has been pushed inadvertently into the pulp Profuse haemorrhage from the exposure site Pus or exudates at the exposure site or very large exposure

Technique of Direct Pulp Capping

Complications
Slow onset of pulpal necrosis requiring further endodontic treatment.

Avoid direct pulp capping in primary teeth

Because:
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.

Pulpotomy
The 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 of tissue in the canals.

Non-vital Pulpotomy
The removal of non-vital (infected) coronal pulp tissue and treatment of the non-vital pulp tissue in the canals Pharmacologically.

Vital Pulpotomy techniques

Calcium Hydroxide Pulpotomy

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

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.

Formocresol
Formalin (formaldehyde) 37% Tricresol (cresol) Glycerin Water 19ml 35ml 25ml 21ml

Single-visit Formocresol Pulpotomy

Success rate 98%

Indications
Carious or mechanical exposures in vital primary teeth.

Contra-indications
Spontaneous pain pain at night Swelling Fistula Tenderness to percussion Pathological mobility External root resorption Internal root resorption Periapical or inter-radicular radiolucency Pulp calcifications Pathological external root resorption Pus or serous exudate at the exposure site Uncontrollable haemorrhage from the amputated pulp stumps

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

Variations in Technique
Time of formocresol application Dilution of formocresol Omission of formocresol from sub-base

Concerns Regarding Formocresol

Local toxicity Systemic toxicity Carcinogenicity and mutagenicity

Diagrammatic Representation of Completed Pulpotomy

Amalgam

Cement

Zinc-oxide Eugenol Paste

Vital pulp

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

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

Disadvantage
The solution shelf-life is only one week,

N2 Pulpotomy
One- stage pulpotomy procedure
Success rate claimed 98%

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, the radicular stumps continue to bleed excessively. When the time factor or lack of cooperation from the child make it difficult to complete a single-visit pulpotomy procedure. When an exposure is encountered at the end of a long visit on a young child, who is becoming restless.

Contra-indications
Prolonged bouts of spontaneous pain.
Evidence of periapical infection. Abscess or sinus. Wide open apices that may allow the medicament to escape.

Technique
First visit
Place 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

Non-vital Pulpotomy or Two-visit Disinfection Pulpotomy or Mortal Pulpotomy

Success 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.

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.

Technique of Non-vital Pulpotomy

First visit
Open pulp chamber &remove infected coronal pulp

Second visit
Open the tooth (symptomless) Remove the cotton pellet

Irrigate the chamber

Place cotton pellet moistened with Beechwood cresote in the chamber Seal for 7-10 days Place zinc-oxide eugenol paste over the floor of the pulp chamber

Give cement lining

Restore the tooth

PULPECTOMY
For 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).

Follow-up of a Pulp Treated Primary Tooth

Clinical examination every 6 months Radiographic examination every 12-18 months

Clinical evidence of failure:

Pain Swelling Presence of a fistula Pathological mobility

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 permanent tooth germ. Inflammatory follicular cyst.

ENDODONTIC TREATMENT FOR YOUNG PERMANENT TEETH

Pulp may be exposed by
Caries Trauma Accidental exposure during cavity preparation

Choices of Treatment procedures

Pulp capping.
Indirect pulp capping Direct pulp capping

Apexogenesis (vital pulpotomy). Apexification (Induction of root end repair).

Pulp Capping
(already discussed)

Apexogenesis
(vital Pulpotomy)
It is the amputation of the coronal pulp and treatment of the vital pulp stumps with calcium hydroxide. Aim: To permit normal apical closure.

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.

Contra-indications
Clinical or radiographic evidence of periapical infection.

Persistent haemorrhage from the amputated pulp stumps.

Non-vital pulp. Pus in the root canals.

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

Follow-up
Calcific tissue forms within 6 8 weeks
The tooth should be kept under radiographic review at 6 monthly, then yearly, intervals. Once the apex is closed, conventional root canal therapy is carried out.

Complications
Rarely, pulpal necrosis and apical infection occur.

Partial pulpotomy

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 canal therapy.

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 not lend themselves to undercutting. Apical surgery further reduce the length of the root which is already short because of its incomplete formation.

Therefore induction of root-end repair (apexification) is a preferred procedure in non-vital permanent teeth with open apices.

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.

Contra-indications
Medical reasons for avoiding root canal therapy. Clinical and radiographic evidence of gross apical infection and bone loss.

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

Calcium Hydroxide Replacement

Follow-up
Post-operative follow up at 4 - 6 monthly intervals 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).

Follow-up (continues)
Calcific repair completion take 6 18 months

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.

Mineral Trioxide Aggregate

Torabinejad, 1993

A relatively new material:

Alkaline pH Biocompatible Prevent bacterial leakage Effective in moist environment

Uses:
Pulp capping Root end repair (Apexification) Perforations

Modified Formocresol Pulpotomy

Thank You