padriatic endodontics

7/28/2019 padriatic endodontics

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ENDODONTIC

TREATMENT FOR THEPRIMARY TEETH


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The successful treatment of the pulpally involved tooth is toretain that tooth in a healthy condition so it may fulfill its role asa useful component of the primary and young permanentdentition.


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Premature loss of primary teeth from dental cariesand infection may result in the following sequela

Loss of arch length

Insufficient space for erupting permanent teeth Ectopic eruption and impaction of premolars

Mesial tipping of molar teeth adjacent toprimarymolar loss

Extrusion of opposing permanent teeth

Shift of the midline with a possibility of crossbite


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It is for this reason that maximum attemptsmust be made to preserve primary teeth in ahealthy state until normal exfoliation occurs.


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The basic differences between the primary and thepermanent teeth are these:

1. Primary teeth are smaller in all dimensions than the

corresponding permanent teeth.2. Primary crowns are wider from mesial to distal in

comparison to their crown length than arepermanent crowns.


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3. Primary teeth have narrower and longer roots incomparison to crown length and width than dopermanent teeth.

4. Primary teeth are markedly more constricted at the

dentin-enamel junction than are permanent teeth.

5. The facial and lingual surfaces of primary molarsconverge occlusally so the occlusal surface is muchnarrower in the facial-lingual than the cervical width.


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6. The roots of primary molars flare out nearer the cervix,and they flare more at the apex, than do the rootsof permanent molars.

7. The enamel is thinner, about I mm, on primary teeththan on permanent teeth and it has a more consistentdepth.8. The thickness of the dentin between the pulp chambers and

the enamel in primary teeth is less than in permanent teeth.

9.. The pulp chambers in primary teeth are comparativelylarger than in permanent teeth.10. The pulp horns, especially the mesial horns, are higher in

primary molars than in permanent molars.


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A suggested outline for determining the pulpal statusof cariously involved teeth in children involves thefollowing:

Visual and tactile examination of carious dentin andassociated periodontiumRadiographic examination of

a. periradicular and furcation areasb. pulp canalsc. periodontal spaced. developing succedaneous teeth

. History of spontaneous unprovoked pain


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Pain from percussion

Pain from mastication

Degree of mobility

Palpation of surrounding soft tissues Size, appearance, and amount of hemorrhage

associated with pulp exposures


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Pulp therapy for primary and young permanentteeth involves the following techniques:

1. Indirect pulp capping

2. Direct pulp capping

3. Coronal pulpotomy

4. Pulpectomy


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This approach has gained increased worldwidepopularity in recent years.

Rationale:

To arrest the carious process and provide conditionsconducive to the formation of reactionary dentin

To promote pulpal healing and preserve the vitality ofpulp tissue

Indications: Tooth with a deep carious lesion

No signs or symptoms indicative of pulpal pathosis


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Procedure: Local anesthesia Good isolation with rubber dam

Removal of all caries at the enamel-dentinejunction

Judicious removal of soft deep carious dentine

Placement of appropriate lining material . Definitive restoration to achieve optimum external

coronal seal (ideally an adhesive restoration or

preformed crown)


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This approach has limited application and is generallynot recommended for primary molars.

Rationale:

To encourage the formation of a dentine bridge at thepoint of pulpal exposure with preservation of pulpalhealth and vitality

Indications:

Asymptomatic tooth Small traumatic (non-carious) pulpal exposure


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Procedure: Local anesthesia

Optimum isolation with rubber dam

Gentle application of cotton pledget soaked inwater/saline to stem any pulpal haemorrhage

Application of hard-setting calcium hydroxidepaste or mineral trioxide aggregate (MTA)

Definitive restoration

Clinical outcome:

Prognosis is reported to be generally poor.


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is the the surgical removal of the entire coronalpulp presumed to be partially or totally

inflamed and quite possibly infected, leavingintact the vital radicular pulp within the canals.

A germicidal medicament is then placed overthe remaining vital radicular pulp stumps at

their point of communication with the floor ofthe coronal pulp chamber.

A restoration is placed over the remaining vitalpulp


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Rationale:

To remove the coronal pulp, which has beenclinically diagnosed as irreversibly inflamed,

leaving behind a possibly healthy or reversiblyinflamed radicular pulp


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Vital pulpotomy Indications

Asymptomatic tooth or only transient pain

A carious or mechanical exposure of vital

coronal pulp tissue


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Contraindications: a nonrestorable tooth, tooth nearing exfoliation or with no bone

overlying the permanent tooth crown, a history of spontaneous toothache, evidence of periapical or furcal pathology, a pulp that does not hemorrhage, inability to control hemorrhage following a

coronal pulp amputation, a pulp with serous drainage the presence of a fistula


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Procedure:

Local anesthesia

Good isolation with rubber dam

Removal of caries

Complete removal of roof of pulp chamberwith a non-end cutting bur

Removal of coronal pulpal tissue with sharpsterile excavator or large round bur in a slowhandpiece


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Attain initial radicular pulpal haemostasis bygentle application of sterile cotton pledgetmoistened with saline (haemostasis should beachieved within four minutes)

Selection of medicament for direct application toradicular pulp stumps to include any of thefollowing:

15.5% ferric sulphate solution

20% (1:5 dilution) Buckleys formocresol solutionapplied to radicular pulp on a cotton pledget forfive minutes to achieve superficial tissue fixation

MTA paste applied over radicular pulp


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Application of a lining (if appropriate) such asreinforced glass ionomer or zinc oxide eugenolcement

Definitive restoration to achieve optimumexternal coronal seal (ideally an adhesiverestoration of preformed metal crown)


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Contraindications:

nonrestorable teeth

soon to be exfoliated

necrotic.


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Procedure:

The steps are the same as for the one-appointmentprocedure.

A cotton pellet moistened with dilutedformocresol is sealed into the chamber for 5 to 7days with a durable temporary cement.

At the second visit, the temporary filling andcotton pellet are removed and the chamber isirrigated with hydrogen peroxide.

A ZOE cement base is placed.

The tooth is restored with a stainless steel crown


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Rationale:

To reduce pulpal inflammation and/orsymptoms in order to facilitate subsequent

pulpotomy or Pulpectomy procedure Indications:

Non-compliant child who may require

inhalation sedation for further treatment Hyperalgesic pulp (adequate analgesia not

achieved)


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Procedure: Local anesthesia Good isolation with rubber dam Removal of caries Place a small pledget of cotton wool loaded with

steroidal antibiotic paste (LedermixTM) directly overexposure site (tooth is usually too sensitive to removeentire roof of pulp chamber)

Place a well-sealed temporary dressing (IRM -without

undue pressure) over the cotton pledget Recall after 714 days and proceed with a pulpotomy

or Pulpectomy technique (depending on clinicalfindings)


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It means complete removal of the pulp from atooth, that is irreversibly infected or necrotic dueto caries or trauma.

Rationale

To remove irreversibly inflamed or necroticradicular pulp tissue and gently clean the rootcanal system

To obturate the root canals with a filling material

that will resorb at the same rate as the primarytooth and be eliminated rapidly if accidentallyextruded through the apex


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Indications:

Radicular pulp exhibiting clinical signs ofhyperemia such as excessive hemorrhage.

Necrotic pulp with minimum tooth resorption. Traumatized primary incisors in children

under (5years.)

Primary teeth with furcal or periapicalpathology

Presence of abscess


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Contraindications:

Non-restorable crown.

Extreme mobility. Advanced internal and external root

resorption.

Extensive bone resorption

Perforated pulpal floor

Primary teeth with underlying dentigerouscyst or granuloma.


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Problems of root canal morphology.

Possibility of damage to permanentsuccessor

Difficult to maintain hermetic seal because ofphysiologic root resorption.

Resorbable root canal filling


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A one- or two-stage Pulpectomy may beundertaken depending on whether the radicularpulp is irreversibly inflamed or non-vital(with/without an associated periradicular

pathosis). If infection is present, and the presence of an

exudates does not allow drying of the canal,consideration should be given to the two-stage

Pulpectomy technique, where the root canals maybe dressed with an antimicrobial agent for 710days and subsequently obturated at the secondvisit.


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Pre-operative radiograph showing all roots and

their apices

Local anesthesia

Rubber dam isolation Removal of caries

Removal of roof of pulp chamber preferably with

non-end cutting bur

Removal of any remains of coronal pulp tissuewith sharp sterile excavator or large bur in slow

handpiece


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Note whether radicular pulp is bleeding (one-stage procedure) or necrotic (usually requiringtwo-stage procedure)

Identify root canals Irrigate with normal saline (0.9%),

Chlorhexidine solution (0.4%) or sodiumhypochlorite solution (0.1%)


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Estimate working lengths of root canalskeeping 2-3 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


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If infection present (canal exudates and/orassociated sinus) dress root canals with non-settingcalcium hydroxide and temporize (two-stageprocedure)

If canals can be dried with paper points, obturate

root canals by injecting or packing a resorbable pastee.g. slow-setting pure zinc oxide eugenol,

paste or Iodoform paste Definitive restoration to achieve optimum external

coronal seal (ideally a preformed crown)


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Clinical outcome

86% clinical success at 36 months follow up(lower success rates found at longer follow-up

times

Review

clinical and radiographic review following anyprimary molar pulp therapy is mandatory


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padriatic endodontics

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