Pulp Therapy in Pediatric Dentistry

Dr. Jeff Johnson Division of Pediatric Dentistry Department of Oral Health Science University of Kentucky

Pulp Therapy in Pediatric Dentistry --Vital Pulp Therapy- Permanent Tooth Pulpotomy
Objectives
Maintain vitality of radicular pulp

Achieve root-end closure (Apexogenesis)

Eliminate need for apicoectomy

Facilitate GP obturation with apical stop

Pulp Therapy in Pediatric Dentistry --Vital Pulp Therapy- Permanent Tooth Pulpotomy Agents
Formocresol

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Objectives of Non-Vital Pulp Treatment (Primary Teeth)
Maintain tooth free of infection Achieve biomechanical cleansing and canal obturation Promote physiologic resorption Maintain space and function

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Non-Vital Pulp Treatment (Primary Teeth)
Choices
Pulpectomy (most are partial due to anatomy) Extraction

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Pulpectomy Indications/Considerations

Strategic importance of tooth (2nd primary molar with unerupted 6-yr molar) Sufficient remaining tooth structure Poor chance of vital pulp treatment success Adequate remaining root Cooperative patient

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Pulpectomy Contraindications

A non-restorable tooth A tooth with a mechanical or carious perforation of the floor of the pulp chamber Pathologic root resorption involving more than onethird of the root Pathologic loss of bone support resulting in loss of the normal periodontal attachment The presence of a dentigerous or follicular cyst Radiographically visible internal root resorption

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Pulpectomy Technique

1. 2. 3.
4. 5. 6. 7.

Achieve adequate anesthesia and rubber dam isolation. Remove all caries. Remove the roof of the pulp chamber with a high-speed handpiece. Amputate the coronal aspect of the pulp tissue with a large round bur in a slow-speed handpiece. The remaining pulp tissue occupying the root canals is removed using endodontic files at a predetermined working length, approximately 1 to 2 mm short of the root apices. The canals should be enlarged several sizes beyond the size of the first file that fits snugly into the canal to a minimum final size of 30 to 35. Throughout root canal instrumentation, the canals should be irrigated with sodium hypochlorite to aid in debridement.

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Pulpectomy Technique (continued)
8. Dry the canals with sterile paper points. 9. The canals are filled with a treatment paste (Zinc Oxide/Eugenol at UKCD) using a pressure syringe. 10. The tooth is restored with a stainless steel crown.

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy--

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Criteria for an ideal pulpectomy obturant (treatment paste)
Antiseptic Resorbable Harmless to the adjacent tooth germ Radiopaque Non-impinging on erupting permanent tooth Easily inserted Easily removed

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Apexification (Young Permanent Teeth)
Apical closure of an incompletely formed root Implemented when apexogenesis has failed Necrotic tissue removal short of the apexification site Agent is placed in canals to achieve closure/apical stop

Apexification Recall Schedule

Calcium Hydroxide Rotation
3-6 month intervals (Andreasen, 1994)

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Action of Calcium Hydroxide in Apexification
Bactericidal Low grade irritation inducing hard tissue barrier formation Dissolves necrotic debris

Forms of Calcium Hydroxide

Caliscept Self-mixed (CaOH + sterile water or local anesthetic)

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- Evaluation of Success

Asymptomatic Radiographic absence of pathology Continued root development Hard tissue barrier at apex Responsive pulp

Pulp Therapy in Pediatric Dentistry --Non-Vital Pulp Therapy- In Review. . .

FYI
Comparison between File Size and Needle for Pressure Syringe
Standard File
15-30 40 50 70-80 90-100

Needle Gauge
30 27 25 22 18

References
Barr Elizabeth, Flaitz Catherine, Hicks John. A retrospective radiographic evaluation of primary molar pulpectomies. Pediatric Dentistry, Vol. 13, Number 1, 1991: 4-9. Dummett, Cliff. Pulp Therapy in Pediatric Dentistry. Louisiana State University School of Dentistry, April 16, 2003. Georig Albert C., Camp Joe H. Root canal treatment in primary teeth: a review. Pediatric Dentistry, Vol. 5, Number 1, 1983: 33-37. Nash David A. Pulpal Therapy, Module 6. West Virginia University School of Dentistry. Mink, John R. and Spedding, Robert. Pediatric Pulp Treatment. University of Kentucky College of Dentistry. Pinkham, J. R., senior editor. Pediatric Dentistry, Infancy through Adolescence, Third Edition. W.B. Saunders Company, 1999.

Walton, Richard E. and Torabinejad, Mahmoud. Principles and Practice of Endodontics, Second Edition. W.B. Saunders Company, 1996.
The Handbook, Second Edition. American Academy of Pediatric Dentistry, 1999.