Pediatric endodontics can be confusing and challenging. Choosing the right treatment plan is dependent on a multitude of factors:
primary vs. permanent tooth, pulpal state, open vs. closed apex, estimated retention time for the tooth, and a variety of materials to use.
To make things just a bit tougher, you’re usually dealing with a patient with limited cooperation and with a very anxious parent by their side.
We are here to lighten your load just a bit. Over the next four days, we are presenting a go-to-guide in pulp therapy when treating primary and immature permanent teeth.
This is a guide you can always refer to, and according to the patient’s clinical presentation – choose the appropriate treatment plan.
Primary Teeth
VITAL PULP THERAPY
Case Presentation:
- A tooth with a normal pulp, and deep caries.
Treatment:
- Place a protective liner, thinly applied, on the dentin in proximity to the underlying pulpal surface of a deep cavity. This allows the covering of exposed dentin tubules between the final restoration and the pulp.
- Use of MTA, trisilicates cements, or calcium hydroxide is at the discretion of the clinician – all showing similar success rates.
Post-Op Objectives:
- This procedure allows for pulp healing, tertiary dentin formation and minimizes bacterial leakage.
- Post-op assessment should show no signs of sensitivity, pain or swelling.
INDIRECT PULP TREATMENT
Case Presentation:
- A primary tooth with deep caries, showing no signs of pulpitis or with reversible pulpitis.
- The deepest carious dentin is not removed to avoid pulp exposure.
- Clinical and radiographic exams should show a vital pulp – in order for the pulp to be able to heal from the carious insult.
Treatment:
- A radiopaque liner (dentin bonding agent, resin modified glass ionomer, calcium hydroxide, or MTA) is placed over the carious dentin, stimulating healing and repair.
- The type of liner placed does not affect the success of the treatment.
- The tooth should then be restored with a material that seals it from microleakage.
Post-Op Objectives:
- To seal the involved dentin from the oral environment.
- To preserve tooth vitality.
- No post op sensitivity, pain or swelling should be evident.
- No radiographic signs of pathologic external, internal root resorption or pathologies should be seen.
- The should be no harm to the succedaneous tooth.
*Note: In a tooth with reversible pulpitis, there is an option to put an interim therapeutic restoration, with glass ionomer cement, and wait for signs of pulpitis to resolve. Once resolved – indirect pulp treatment can initiated. However, there is no evidence in literature that indicates a higher success rate for this extra step.
Indirect pulp treatment has shown higher success rates than direct pulp treatment and pulpotomy, and does not alter the exfoliation time of the tooth. So, indirect pulp treatment is indicated over direct pulp treatment when the pulp is normal or with reversible pulpitis, and there is no pulp exposure.
DIRECT PULP CAPPING
Case Presentation:
- Primary tooth with a normal pulp, with a small pulpal exposure of one millimeter or less.
Treatment:
- When there is a pinpoint exposure of the pulp during the preparation of the cavity, or through traumatic injury, MTA or calcium hydroxide can be placed to cover the exposed pulp.
- The tooth is then restored with a material that seals the tooth from microleakage.
Post-Op Objectives:
- The tooth vitality is maintained.
- No post-op treatment signs of sensitivity, pain or swelling should be seen.
- Pulp healing and reparative dentin formation should result.
- No radiographic signs of pathologic external, progressive internal resorption, or apical/furcal pathology should be seen.
- There should be no harm to the succedaneous tooth.
PULPOTOMY
Case Presentation:
- Pulpal exposure when caries removal causes pulp exposure larger than one millimeter.
- Pulpal exposure due to trauma.
- Normal pulp or with reversible pulpitis.
- No radiographic signs of infection/ pathological resorption.
Treatment:
- The coronal pulp is amputated, pulpal hemorrhage controlled, and the remaining vital radicular pulp surface is treated with medicament.
- Only MTA and formocresol have shown to be long term clinically successful medicaments – for teeth expected to be retained for 24 months or longer.
- The American association of Pediatric Dentists (AAPD) recommends against the use of calcium hydroxide for pulpotomy.
- After the coronal chamber is filled with a suitable base, the tooth is restored to prevent microleakage, and possible stainless steal crown (depending on the amount of tooth structure remaining).
Post-Op Objectives:
- The radicular pulp should remain asymptomatic, without signs of sensitivity, pain or swelling.
- No post-operative radiographic signs of pathology.
- Internal resorption may be self-limiting and stable.
- There should be no harm to the succedaneous tooth.
PULPECTOMY
Case Presentation:
- A primary tooth with irreversible pulpitis or necrosis due to caries or trauma.
- A primary tooth treatment planned for pulpotomy in which the radicular pulp has signs of suppuration/ purulence (signs of irreversible pulpitis or necrosis).
- The tooth should have no or minimal signs of resorption.
Treatment:
- The root canals are debrided and shaped with hand or rotary files, and then irrigated.
- Chlorhexidine, 1%-5% sodium hypochlorite, or sterile water/saline can be used for irrigation – as one recent review showed no clinical difference in success rate for each.
- A resorbable material such as non-reinforced zinc/oxide eugenol, iodoform-based paste, or combination of paste of iodoform and calcium hydroxide can be used to fill the canals.
- A recent review has shown ZOE performed better than iodoform based pastes.
- The tooth is then restored to prevent microleakage.
- The tooth should be clinically and radiographically monitored at least for 12 months.
Post-Op Objectives:
- Radiographic infection process should resolve in 6 months, with evidence of bone deposition in pre-treatment radiolucent areas.
- Pretreatment clinical symptoms should resolve in weeks.
- There should be no radiographic sings of over-extension of root filling materials.
- The treatment should permit resorption of root filling material to allow of succedaneous tooth eruption.
LESION STERILIZATION/ TISSUE REPAIR
Case Presentation:
- When a primary tooth has signs of irreversible pulpitis or necrosis.
- When a primary tooth is to be maintained for less than 12 months.
Treatment:
- No instrumentation of the root canals is done, but an antibiotic mixture is placed in the pulp chamber in order to disinfect the root canals.
- The canal orifices are enlarged with a large round bur to create medication receptacles.
- The walls of the chamber are cleaned with phosphoric acid, rinsed and dried.
- A three antibiotic mixture of clindamycin, metronidazole, and ciprofloxacin is combined with a liquid vector of polyethylene glucol and macrogol. This paste is placed in the receptacles created.
- The pulp chamber floor is then covered with glass ionomer cement.
- The tooth is should then be restored with a stainless steel crown.
Post- Op Objectives:
- Evidence of radiographic infections should resolve.
- Evidence of bone deposition should be seen in pre-treatment radiolucent areas.
- Pre-treatment clinical symptoms should resolve.