Abdelhamied Y Saad1*
1Professor and Head of Endodontic Department, Pharos University in Alexandria, Faculty of Dentistry, Egypt
Correspondence author: Bakopoulou Athina, BDS, MSc (Egypt), Ph.D., Endo. Cert. (USA), Professor and Head of Endodontic Department, Pharos University in Alexandria, Faculty of Dentistry, Egypt;
E-mail: [email protected]; [email protected]
Published Date: 23-04-2024
Copyright© 2024 by Saad AY. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
The purpose of this educative work was to evaluate different techniques used for endodontic treatment of different pediatric cases including primary and young permanent teeth. The data of this investigation were obtained from some text books, endodontic researches, internet and personal data. Several techniques were utilized including indirect and direct pulp capping, pulpotomy, for vital pulps and pulpectomy for non-vital pulps. The results demonstrated successful outcome with long term follow-up. It was concluded that endodontic therapy can preserve dental arches, as well as the surrounding periodontium in good conditions and maintains the vitality of dental pulps of primary and young permanent teeth.
Keywords: Indirect and Direct Pulp Capping; Pulpotomy; Pulpectomy
Introduction
This teaching article collected from some endodontic text books, researches, internet, Google scholar database, Midline act. Others from my educative materials to make a complete story concerning “Endodontic Therapy for Primary and Young Permanent Teeth”. The dentin -pulp complex of the primary teeth has a similar response to dental caries as the permanent teeth. The treatment modalities for both also similar.
A Comparison of Primary and Permanent Tooth Anatomy
Fig. 1,2 showing the difference between the primary and permanent teeth.
Figure 1: Showing the difference between deciduous and permanent teeth.
Figure 2: A and B: Caries can progress and infect the deciduous pulps more quickly than in permanent teeth.
Goal of Endodontic Therapy for Primary and Young Permanent Teeth
To maintain:
Pediatric endodontic therapy can be divided into:
Medical Factors in Determining if a Primary Tooth Should be Saved:
There are certain medical conditions that contraindicated endodontic therapy in the primary dentition.
Contraindications:
Indications (To avoid extraction):
The type of endodontic therapy chosen must be based on the:
Figure 3: Primary 2nd molar with no successor has received RCT. Such teeth may last for many years.
Vital Pulp Therapy
Treatment of Deep Caries (Indirect Pulp Capping)
The ultimate objective of this treatment is to maintain p. vitality by:
Figure 4: Enamel caries and sclerotic dentin (dye-filled dentinal tubules except sclerotic area – red arrow).
Figure 5: Reparative dentin (red arrow-H&E X25).
Treatment
Figure 6: Dycal [CA (OH)2].
Figure 7: Coronal pulp tissue is inflamed even before the pulp is exposed.
Figure 8: Note the early inflammatory changes in the odontoblast layer (H&E stain X25).
Figure 9: Indirect pulp capping (A and B).
Figure 10: A: Ca(OH)2; B: lasting temporary restoration.
Post-operative evaluation can be performed by removing the amalgam and cement with sterile burs and rubber dam isolation, if:
This means the remaining caries can then be removed successfully without pulp exposure. Scotchbond MultiPurpose can be used successfully for pulp protection instead of Ca(OH)2. Recently, the tooth can be restored with adhesive restorations (amalgam and St. St. crowns are becoming less desirable). The success rate is above 90%.
Criteria for Success
Vital Pulp Therapy for Children (Direct Pulp Capping)
Is a treatment option for teeth with pinpoint-sized traumatic or mechanical vital pulp exposure with no signs or symptoms of irreversible pulpitis. The exposed pulp is covered by Ca(OH)2 or MTA and the tooth receives a permanent restoration (Fig. 11,12). Use rubber dam to prevent contamination.
Figure 11: A and B: Direct pulp capping.
Figure 12: A: Ca(OH)2 or MTA; B: Protective base(ZOE); C: Amalgam restoration.
The patient should not experience any pain and reparative dentin is expected to form. Direct p. capping of a carious pulp exposure is not recommended (Fig. 13,14). It should be performed in older children where the tooth is not expected to last for more than a couple of years until normal exfoliation.
Figure 13: Caries exposes the pulp. Direct pulp capping is contraindicated.
Figure 14: Inflammatory changes involving the entire pulp in response to proximal caries.
Pulpotomy
Is a procedure for teeth with healthy pulps or teeth with symptoms of reversible pulpitis and deep caries with pulp exposure.
Figure 15: Deep caries removed and cavity preparation is performed for stainless steel crown prior to placement of a protective liner and the restoration.
Protective Liner
Again, it is recommended that all pulp therapies be performed with a rubber dam. Clinical signs and symptoms should resolve within about 1-2 weeks. Tooth should remain asymptomatic exhibiting no pathologic mobility, sensitivity or pain.
Formocresol
Is the most common pulpotomy medicament used in pediatric dentistry today (Fig. 16).
Figure 16: Armamentarium for the pulpotomy technique.
Contraindications
Mechanism of Action
It acts through the aldehyde group of formaldehyde, forming bonds with the side-group of amino acids of both the bacterial proteins and remaining pulp tissue. Therefore;
Accordingly, the protein-binding properties and the inhibition of enzyme together results in:
Clinical Procedures
Fig. 17-29 showing the technique used for teeth need formocresol pulpotomy.
Figure 17: A and B: Administration of local anesthesia with the use of topical analgesic and then Isolate the tooth with rubber dam.
Figure 18: Caries removal with a slow- speed round, large and old bur.
Figure 19: Removal of the roof with a high-speed bur and water spray.
Figure 20: Removal of the coronal pulp with a spoon excavator, then use hemostasis with sterile cotton pellets.
Figure 21: Formocresol is placed with slight pressure for 5 mins. (full- strength or diluted).
Figure 22: Apply formocresol for 5 min. (squeeze in gauze to remove excess).
Figure 23: Placement of ZOE base (after control of the bleeding).
Figure 24: Pulp chamber is filled with cement.
Figure 25: Restoration and stainless-steel crown.
Figure 26: Stainless steel crown.
Figure 27: Pre-treatment radiograph showing deep caries.
Figure 28: One-year post-treatment radiograph.
Figure 29: Five-year follow-up radiograph.
The Formocresol-treated pulp responded by 3 zones:
Systemic distribution of formocresol to the liver, lung, muscles, heart, spleen, kidney was found (animal studies). Systemic absorption decreases by time indicating that it compromises the pulpal circulation and limits its systemic uptake. Some researchers have revealed the allergic effects (skin patch) as well as the mutagenic and carcinogenic potential of formocresol. Failure is usually detected in radiograph as
Figure 30: Formocresol pulpotomy failure (internal resorption with bifurcation radiolucency).
Glutaraldehyde
It was used in 1975 as an alternative pulpotomy fixed medicament. It is biologically accepted and capable to maintain the vitality of the radicular pulp. Several workers have stated that glutaraldehyde:
Applying glutaraldehyde directly to the pulp stump with medicated pellets for 5 mins., is better than incorporating it into the cement sub-base.
Freeze-Dried Bone
Few studies were performed using it as a pulpotomy agent using monkey’s primary teeth. Histologically;
Electrosurgery
Technique
Limit the amount of contact of the electrosurgical unit with pulp to prevent overheating of pulp tissue. Histologically;
After few months, chronic inflammatory cells and fibroblasts with some reparative dentin can be seen below this area. However;
Many researchers do not recommend electrosurgical pulpotomy in spite it is faster and no risks of formocresol side effects.
Laser
Ferric Sulfate
It has been used as a hemostatic agent for crown and bridge impressions. In pulpotomy, a 15.5% solution is applied over the pulp stumps for 10 to 15 seconds. Fig. 31-33 showing clinical application of ferric sulfate. Histologically;
Figure 31: Ferric sulfate.
Figure 32: Bleeding in the pulp chamber after coronal pulp amputation.
Figure 33: Bleeding arrested after application of ferric sulfate.
Figure 34: Radiograph showing internal resorption after ferric sulfate pulpotomy.
Figure 35: A photograph shown resorption resulted in perforation B.
Figure 36: Space maintainer.
Mineral Trioxide Aggregate (MTA)
Technique
Figure 38: MTA (gray).
Figure 39: A and B: Showing mixing gray MTA.
Sodium Hypochlorite
At low concentrations it has been to be:
Technique
The success rate for this treatment is similar to that of Formocresol.
Non-vital Pulp Therapy for Children (Pulpectomy)
Indication is when a tooth has irreversible pulpitis extending to the radicular pulp or has necrotic pulp. Treated by a pulpotomy and excessive hemorrhage (hyperemia) is encountered at the time of treatment. Presence of a chronic, draining sinus or an acute abscess with or without cellulites (Fig. 40-43).
Figure 40: Irreversible inflammation extending to the radicular pulp.
Figure 41: Necrotic pulp.
Figure 42: A chronic draining sinus (arrow) without cellulitis.
Figure 43: Acute periradicular abscess with cellulitis.
Contraindications
Figure 44: A non-restorable tooth (arrow).
Figure 45: Internal resorption with furcation radiolucency (arrow).
Figure 46: Advanced pathological root resorption. Extraction is the treatment of choice.
Figure 47: Primary tooth with furcation pathology.
Pulpectomy in Pediatric Dentistry Means:
Figure 48: For obturation of root canal of the deciduous tooth.
Clinical Procedure
Pulpotomy is simple and some children are not cooperative enough to sit for pulpectomy procedure.
Figure 49: A-E: Obturation with ZOE.
Figure 50: Large carious lesion involving the pulp.
Figure 51: Obturation with ZOE.
Figure 52: One year later.
Figure 53: Care should be taken not to disturb the subjacent permanent tooth germ (arrow).
Figure 54: A and B: Pulpectomy and obturation with gutta- percha in a retained primary molar with no successor.
Figure 55: Primary incisor has been exfoliated (retained ZOE – arrow).
Figure 56: A-E: Pulpectomy & RCT filled with Ca(OH)2.
Figure 57: Enamel hypoplasia.
Figure 58: Enamel hypocalcification.
Figure 59: Close relationship between the erupted primary teeth and their permanent successors.
Figure 60: Bite-wing radiograph of the mixed dentition.
Conclusion
This educative research was conducted to discuss the role of the dental caries that affect the primary and young permanent teeth. If neglected, it may lead to pulp inflammation, pulp necrosis and un-restorable teeth followed by extraction. Subsequently, this may result in more detrimental effect on the dentition, pain, infection, periodontal diseases and loss of function.
This work was taken from some text books, endodontic researches, internet and personal data. Endodontic treatment to maintain the integrity of the teeth and supporting structures include indirect pulp capping, direct pulp capping and pulpotomy for vital pulps or pulpectomy for non-vital pulps. Favorable results were obtained and revealed that prevention or the early restoration minimizing the pulp inflammation, infections or extraction.
These findings demonstrated that correct endodontic treatment maintains the health of the teeth and surrounding tissues. This indicating that proper examination, early and accurate diagnosis of pulp condition, optimal definitive therapy and long-term follow-up should be the goal of endodontic therapy for deciduous and permanent teeth.
Conflict of Interests
The authors have no conflict of interest to declare.
References
Review Article
Received Date: 01-04-2024
Accepted Date: 15-04-2024
Published Date: 23-04-2024
Copyright© 2024 by Saad AY. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation: Saad AY. Endodontic Therapy for Primary and Young Permanent Teeth (Pediatric Endodontics). J Dental Health Oral Res. 2024;5(1):1-31.
Figure 1: Showing the difference between deciduous and permanent teeth.
Figure 2: A and B: Caries can progress and infect the deciduous pulps more quickly than in permanent teeth.
Figure 3: Primary 2nd molar with no successor has received RCT. Such teeth may last for many years.
Figure 4: Enamel caries and sclerotic dentin (dye-filled dentinal tubules except sclerotic area – red arrow).
Figure 5: Reparative dentin (red arrow-H&E X25).
Figure 6: Dycal [CA (OH)2].
Figure 7: Coronal pulp tissue is inflamed even before the pulp is exposed.
Figure 8: Note the early inflammatory changes in the odontoblast layer (H&E stain X25).
Figure 9: Indirect pulp capping (A and B).
Figure 10: A: Ca(OH)2; B: lasting temporary restoration.
Figure 11: A and B: Direct pulp capping.
Figure 12: A: Ca(OH)2 or MTA; B: Protective base(ZOE); C: Amalgam restoration.
Figure 13: Caries exposes the pulp. Direct pulp capping is contraindicated.
Figure 14: Inflammatory changes involving the entire pulp in response to proximal caries.
Figure 15: Deep caries removed and cavity preparation is performed for stainless steel crown prior to placement of a protective liner and the restoration.
Figure 16: Armamentarium for the pulpotomy technique.
Figure 17: A and B: Administration of local anesthesia with the use of topical analgesic and then Isolate the tooth with rubber dam.
Figure 18: Caries removal with a slow- speed round, large and old bur.
Figure 19: Removal of the roof with a high-speed bur and water spray.
Figure 20: Removal of the coronal pulp with a spoon excavator, then use hemostasis with sterile cotton pellets.
Figure 21: Formocresol is placed with slight pressure for 5 mins. (full- strength or diluted).
Figure 22: Apply formocresol for 5 min. (squeeze in gauze to remove excess).
Figure 23: Placement of ZOE base (after control of the bleeding).
Figure 24: Pulp chamber is filled with cement.
Figure 25: Restoration and stainless-steel crown.
Figure 26: Stainless steel crown.
Figure 27: Pre-treatment radiograph showing deep caries.
Figure 28: One-year post-treatment radiograph.
Figure 29: Five-year follow-up radiograph.
Figure 30: Formocresol pulpotomy failure (internal resorption with bifurcation radiolucency).
Figure 31: Ferric sulfate.
Figure 32: Bleeding in the pulp chamber after coronal pulp amputation.
Figure 33: Bleeding arrested after application of ferric sulfate.
Figure 34: Radiograph showing internal resorption after ferric sulfate pulpotomy.
Figure 35: A photograph shown resorption resulted in perforation B.
Figure 36: Space maintainer.
Figure 37: MTA (white).
Figure 38: MTA (gray).
Figure 39: A and B: Showing mixing gray MTA.
Figure 40: Irreversible inflammation extending to the radicular pulp.
Figure 41: Necrotic pulp.
Figure 42: A chronic draining sinus (arrow) without cellulitis.
Figure 43: Acute periradicular abscess with cellulitis.
Figure 44: A non-restorable tooth (arrow).
Figure 45: Internal resorption with furcation radiolucency (arrow).
Figure 46: Advanced pathological root resorption. Extraction is the treatment of choice.
Figure 47: Primary tooth with furcation pathology.
Figure 48: For obturation of root canal of the deciduous tooth.
Figure 49: A-E: Obturation with ZOE.
Figure 50: Large carious lesion involving the pulp.
Figure 51: Obturation with ZOE.
Figure 52: One year later.
Figure 53: Care should be taken not to disturb the subjacent permanent tooth germ (arrow).
Figure 54: A and B: Pulpectomy and obturation with gutta- percha in a retained primary molar with no successor.
Figure 55: Primary incisor has been exfoliated (retained ZOE – arrow).
Figure 56: A-E: Pulpectomy & RCT filled with Ca(OH)2.
Figure 57: Enamel hypoplasia.
Figure 58: Enamel hypocalcification.
Figure 59: Close relationship between the erupted primary teeth and their permanent successors.
Figure 60: Bite-wing radiograph of the mixed dentition.
