PULP THERAPY IN CHILDREN

PULP TX MODALITIES
1. Pulp capping
a. Indirect Pulp Capping
b. Direct Pulp Capping
2. Pulpotomy
a. Formocresol Pulpotomy
b. Calcium Hydroxide Pulpotomy
3. Pulpectomy
a. Deciduous
b. Permanent
4. Apexification

I.GENERAL EXAMINATION
A. HISTORY OF PAIN
1. Provoked pain
2. Spontaneous pain
B. VISUAL EXAMINATION, PALPATION,
PERCUSSION
1. Soft tissue
2. Hard tissue
3. Percussion of tooth for sensitivity
C. VITALITY TEST
1. Sensitivity to thermal changes
2. Electric stimulation (pulp tester)

II.RADIOGRAPHIC EXAMINATION
A. ANATOMIC ASPECTS
1. Widely divergent canals
2. Sharply curved canals
3. Accessory canals
4. Location of pulp horns
5. Shape, size, length and number of roots

B. PATHOLOGIC ASPECTS
1. Depth and proximity of caries to the pulp
2. Degree of pulpal involvement in caries or
trauma
3. Amount of reparative dentin
4. Thickness of periodontal membrane
5. Periapical or furcation involvement
6. Calcific masses in the pulp
7. Internal resorption

C. DEVELOPMENTAL ASPECTS
1. Stage of development
2. Degree of pulp maturity
3. Examples of anomalies



ANALYSIS OF FINDINGS
1. Determine whether the tooth is vital or
nonvital
2. Determine feasibility of tx
a. Tooth is needed in the arch and is not
orthodontically condemned
b. Tooth is restorable
c. Predicted life span before exfoliation will
justify type of tx and restoration
3. Rule out any systemic contraindication for
pulp tx
4. Decide healing potential on the basis of
degree of pulp maturity:
a. Very young pulp (with funnel-shaped
foramen) has excellent healing potential
b. Moderately young pulp has a good
healing potential
c. Aged pulp (with closed apex or
obliterated canals) has less healing
potential
5. Evaluate proximity of infxn or trauma to pulp:
a. Is there an adequate seal of sound
dentin?
b. Is there suspected minute pulpal
exposure?
c. Is pulp actually involved?
6. Evaluate involvement of periapical and
periodontal tissue
7. Make a tentative diagnosis

ADMINISTRATION OF ANESTHESIA
Needle bisecting thumb which approximates
apex of pterygomandibular triangle.
Penetration is medial to internal border of
mandible and lateral to petrygomandibular
raphe.
In children, mandibular foramen is below
occlusal plane.
In adults, it is above occlusal plane

PULPOTOMY
INDICATIONS
Tooth:
1. Primary
2. Permanent
Pain:
1. NO extreme night pains
2. NO unprovoked toothache
3. Pain must NOT be frequent, continuous,
sharp, and penetrating


RADIOGRAPHIC EXAMINATION
1. Probable pulp exposure
2. Normal interradicular periapical tissues
3. Normal root development, no calcifications,
in the pulp chamber or root canals
4. NO internal root resorption
5. NO premature or abnormal external root
resorption

CLINICAL EXAMINATION
1. NO excessive mobility
2. NO gingival pathology or evidence of a
chronic fistulous tract
3. NO disaggreable odor emanating from the
pulp chamber

FORMOCRESOL PULPOTOMY
Remove infected carious dentin before
entering the pulp chamber
Care should be taken to avoid perforation of
the floor of the pulp chamber
Remove the roof of the pulp chamber using
fissure bur
Completely remove the roof of the pulp
chamber and expose the coronal pulp tissue
Walls of the cavity should be diverging
occlusally to make sure roof of the chamber
is completely removed.
There should be no overhanging part of the
roof of the chamber
Removal of the coronal pulp should be down
level of the orifices of each root canal
Amputate the coronal pulp using a STERILE
SHARP and LARGE spoon excavator
Control bleeding using a sterile cotton pellet
Apply pressure for 1-2 mins over the orifices
Apply formocresol (in a cotton pellet) over
the orifices of the canals or the pulp stumps
for 5mins
Pulp stumps will turn grayish or blackish in
color after applying formocresol. This is
known as the zone of fixation
Fill the pulp chamber with a mixture of zinc
oxide eugenol or IRM.
Restore the tooth using SSC

Vital Tissue

o Critical period for re-evaluation
3 months
o Adverse clinical signs and symptoms
(indications of failure of tx)
1. Pain
2. Swelling
3. Mobility

CALCIUM HYDROXIDE PULPOTOMY
Apply cotton to pulp stumps. This should
control hemorrhage within 1-2 mins
Place 2mm layer of calcium hydroxide over
the pulp stumps
Seal the tooth with Zinc oxide eugenol.
ZOE may also be used to fill the tooth
provided the tooth will be restored with a
permanent restoration soon.
An amalgam restoration maybe placed as an
intermediate restoration. This provides a
better restoration if the crown is not to be
placed for several months

SSC maybe cemented as an intermediary
restoration.
Critical period for evaluation 3 months
Zinc Oxide
MIx

SSC
Coagulation
Necrosis
SSC
Calcium
hydroxide
Zinc oxide eugenol
amalgam
PULPECTOMY
-The tx of choice when the degenerative changes in -
the radicular pulp are irreversible.
- Left untreated, these teeth are potentially harmful
to:
1. succedaneous teeth
2. the periapical tissues
3. systemic condition of the child

Effects to the Developing Succedaneous Tooth
include:
1. Formation of a cyst that may envelop the
permanent tooth bud
2. Interruption of amelogenesis
3. Enamel hypoplasia
4. Discoloration
5. Changed eruption sequence
6. Ectopic eruption
7. Axial rotation
8. Retarded root development
9. Loss of permanent tooth bud by exfoliation
through a chronic fistula

Effects to the Periapical Tissues Include:
1. Abscess formation
2. Cyst formation
3. Osteomyelitis

Systemic Rxn Include:
1. Bacteremia
2. Subacute bacterial endocarditis

INDICATIONS
1. Primary incisors with periapical pathology in
a child under age 4 or 4 when esthetics is
of prime concern
2. Primary 1
st
molars prior to the eruption of
primary 2
nd
molars
3. Primary 2
nd
molars prior to the eruption of
1
st
permanent molars
4. The patient has history of pain and/or
elevated temp
5. On clinical examination, the tooth may be
discolored, carious, fractured, or mobile
6. The gingival tissues may show varying
degrees of abscess formation and maybe
sensitive to percussion
7. Roots not more than 2/3 resorbed.

CONTRAINDICATIONS
1. A nonrestorable tooth
2. Pathology extending to the developing tooth
bud
3. Roots are more than 2/3 resorbed
4. Calcified root canals
5. The child is medically compromised or
chronically ill with such diseases as leukemia,
rheumatic heart or chronic kidney disease

Procedure
Extirpate pulp with barbed roach
If canal is narrow, use file
Enlargement of the canal should not be done
File is used just to clean the canal

o Anterior file #80-100
o Posterior file #25-30

Sodium hypochlorite is not recommended as
irrigating soln for deciduous teeth
The ff irrigating solns may be used instead:
o Anesthetic soln
o Normal saline soln
Dry canals with paper points
Working length (WL) should be 2mm short of
the apex
Obturation of the canals. Zinc oxide eugenol
is used to obdurate the canals
Ways of obturating the canal:
o Master point method
o Lentulo spiral method
o Pressure syringe method (insert
needle of pressure syringe into canal
to approximately 2mmfrom apex of
the root)
Root canals obturated with ZOE
Critical period for re-evaluation- 6-12 months
Adverse clinical signs and symptoms
1. Pain
2. Swelling
3. Mobility

APEXIFICATION
Young permanent tooth with open apex (blunderbuss
apex)
Instrument canal within 2mm from apex

Canal filled with:
o Calcium hydroxide
o Cotton
o ZOE
o Zinc phosphate cement


Apexogenesis vs Apexification


Critical period for re-evaluation- 6-12 months
6mos recall sched

If closure of the apex has occurred, proceed with root
canal obliteration by conventional endodontic
method.

If there is no evidence of closure, repeat the
procedure.

ACCIDENTS AND INJURIES TO PRIMARY
ANTERIOR TEETH
1. Prevalence of injuries
2. Diagnostic procedures
3. Classification of traumatic injuries
-WHO
-Andresen
-Ellis
4. Clinical management of injuries

PREVALENCE OF INJURIES
-classification of injuries to anterior teeth applies to
both primary and permanent dentition
- difference lies on the prevalence of the various
types of injuries

Primary Dentition
- fracture is infrequent
- displacement occurs more frequently
- intursion most frequent

Reasons:
More vertical position
Better lip protection
Alveolar bone more pliable

Permanent Teeth
-more susceptible to fracture

Reasons:
1, labially inclined
2.alveolat bone more dense holding the teeth more
firmly

DIAGNOSTIC PROCEDURES
- medical history
- dental history
- hemorrhage
- timing
-dental examination

Dental Examination
1. Soft tissue injuries
o Thoroughly examined lacerations and
contusions of the face. Lips, and
gingival
o Remove any tooth fragments or
debris embedded in the tissue
o Gently cleanse the area to aid in
visual examination
o Develop a plan of tx
2. Hard tissue injuries
o Note extent of crown fracture
o Check for displaced or avulsed tooth
o Note amount of mobility
o Check for pulp exposure
o Examine adjacent and opposing teeth
for injury

3.Radiographic Examination
Evaluate size of the pulp and its proximity to
coronal fracture
Estimate amt of root development
Check for root fractures
Alveolar fractures
Periapical pathology
Previous restorative or endo tx

CLASSIFICATION OF DENTAL INJURIES
Ellis Classification
- modification of the WHO classification
- simplified classification which groups many injuries
- injuires to the alveolar socket and fractures of the
mandible and maxilla are not included in the
classification


TREATMENT
Deciduous Permanent
Class I Smoothen rough
enamel
-smoothen rough
enamel
-selective
recontouring
Class II GI, SOC, SSC, open-
faced SSC
Restore with
composite
Class III Formocresol
pulpotomy
-small exposure w/in
24hrs-DPC
-large exposure w/in
24hrs-pulpotomy
-large exposure after
24hrs-
immature root-
apexification
mature root- RCT
Class IV -pulpectomy
-extraction
-immature root
apexification
-mature root
pulpectomy
Class V -Replantation replacement of a tooth
that has been removed from the alveolus
within 30mins
-Grossman in 1970
-less than 30mins-90%
-30-90mins -43%
- more than 90mins-7%
-longer than 30mins- bench-type endo
Class VI extraction -cervical third- poor
prognosis
Mature root-post
and core
-middle 3
rd

stabilization/splinting
-apical 3
rd

stabilization/splinting
Class
VII
? ?
Class
VIII
extraction Treat as cervical 3
rd

fracture