Dental caries and traumatic dental injuries are still prevalent, despite of the contemporary advances in primary prevention, and treatment of the damage they cause is a major component of paediatric dental practice.
The diagnosis of pulp disease is especially difficult in young patients because they are usually unable to give an accurate account of their symptoms.
One of the key goals of paediatric dentistry is to protect and preserve the pulps of teeth in a healthy state at least until the critical phase of tooth development is complete.
The clinical management of primary and permanent tooth with pulp or periapical disease may be quite different based on the anatomic and histological differences in the two types of teeth.
Diagnosis of pulpal pathosis
It is important to diagnose the likely pulpal status of the concerned tooth in order to determine the most appropriate treatment.
Signs and symptoms
Any history of spontaneous, severe pain, especially at night
Pain on biting
Use of analgesics
The clinical extent of caries, notably the presence of marginal ridge break down*
The presence of intra-oral swelling, fistula or sinus
History of intra-oral or facial swelling
*According to a study, the inflammation of the pulp in primary molars develops at an early stage of proximal carious attack. By the time most proximal caries is manifested clinically, such as marginal breakdown, the pulp inflammation is quite advance. Once the breakdown of marginal ridge is evident, the pulp therapy is invariably required.
Investigations
Gentle finger pressure to determine whether tooth is mobile or tender
Radiographs are mandatory
Pulpal sensitivity tests are not appropriate for primary molars
Treatment options
Indirect pulp capping
It is indicated in a tooth with deep carious lesion showing no signs or symptoms indicative of pulpal pathosis. The aim is to remove the bulk of infected dentine and a small amount of softened dentine may be left in the deepest part of the preparation to avoid pulpal exposure
Procedure
Local anaesthetic is given
Good isolation with rubber dam
Removal of all caries at the enamel-dentine
junction
Judicious removal of soft deep carious dentine
(using slowly rotating large
round steel bur) around the cavity margins
Gentle excavation on the pulpal floor, removing as much as softened dentine as possible without exposing the pulp
Placement of appropriate lining material such as re-inforced glass ionomer cement, a hard-setting calcium hydroxide or zinc oxide eugenol.
Definitive restoration to achieve optimum external coronal seal (ideally an adhesive restoration or preformed crown)
Direct pulp capping
This approach has limited application and is generally contraindicated in primary molars as it leads to failure.
Vital pulpotomy
It involves the coronoal removal of pulp tissue that is diagnosed to be inflamed or infected as a result of deep caries. This leaves an intact radicular pulp tissue upon which a medicament is applied.
Indications
Asymptomatic tooth or only transient pain
Large proximal carious lesion with 1/3rd or more involvement of the marginal ridge in an otherwise restorable tooth
A carious or mechanical exposure of vital coronal pulp
Procedure
Local anaesthetic
Good isolation with rubber dam
Removal of caries
Complete removal of roof of pulp chamber preferably with a non-end cutting bur
Removal of coronal pulpal tissue with sharp sterile excavator (recommended) or large round bur in a slow speed 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 burnished on pulp stumps with microbrush for 15 seconds to achieve haemostasis, followed by thorough rinsing and drying
20% (1:5 dilution) Buckley’s formocresol solution applied to radicular pulp on a cotton pledget for five minutes to achieve superficial tissue fixation
MTA paste applied over radicular pulp with proprietary carrier
- Well-condensed layer of pure calcium hydroxide powder applied directly over radicular pulp
Fill the chamber with zinc oxide eugenol cement, pressing on the zinc oxide with a damp pledget to make sure that it is well condensed in the chamber
Place coronal restoration, preferably a stainless steel crown.
Non-vital Pulpectomy
In this case, irreversibly inflamed coronal as well as radicular pulp is removed to retain a non-vital primary tooth.
Indications
Irreversible pulpitis
Non-vital primary molars or incisors that need to be maintained in the arch
Abscessed primary molars
Good patient compliance
Procedure
One stage pulpectomy:
Pre-operative radiograph showing all roots and apices
Local anesthetic and good isolation is achieved
Access pulp chamber and 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 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
Obturate root canals by injecting or packing a resorbable paste e.g. slow-setting pure zinc oxide eugenol, non-setting calcium hydroxide paste or calcium hydroxide and iodoform paste
Fill the pulp chamber with a cement and restore with stainless steel crown
Two stage pulpectomy:
If active infection is present and there is presence of an exudate that does not allow proper drying of the canal, two-stage technique is considered.
All the steps are same as that of one stage pulpectomy up till removal of radicular pulp. After filing the canals, if there is presence of a discharge and/or is associated with a sinus, the root canals are dressed with non-setting calcium hydroxide and temporized. Systemic antibiotic maybe prescribed.
Alternatively, a small cotton pledget moistened in formocresol or Ledermix (steroidal antibiotic paste) is sealed in the pulp chamber with GIC or IRM for 7 to 14 days. This technique is also known as desensitizing pulp therapy. It is also used in case of a hyperalgesic pulp or when the tooth is too sensitive to remove entire roof of pulp chamber.
In the second visit, the pledget is removed, the canals are cleaned and obturated followed by a stainless steel crown.
References:
Rodd, H. D., Waterhouse, P. J. (2006). Pulp therapy for primary molars. nternational Journal of Paediatric Dentistry.
Welbury, R. (2005). Paediatric Dentistry. 3rd ed. Glasgow: Oxford University Press
Hedge, V. (2011). Pediatric Endodontics- Endodontist’s view. People’s Journal of Scientific Research.
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