Endodontics In Primary Teeth
The need for endodontic treatment in primary teeth is usually related to caries in molars
, with the main objective being to maintain space in order to prevent crowding of the permanent teeth. Normally, the most important time period is before the first permanent molars have reached occlusion. The special features of the primary molar, such as the complicated root anatomy and close relation to the permanent tooth germ and its restricted period of function, make the treatment principles somewhat different from those of permanent teeth.
Wound dressings characteristics, modes of action and reported clinical success rates:
The ideal dressing material for either unexposed or exposed vital pulps should be bactericidal and enhance the repair and healing of the pulp. The dressing also should be biocompatible and not interfere with the physiological process of root resorption. The cost of the material should also be reasonable. Unfortunately, the ideal dressing has still to be discovered. Meanwhile, various dressing materials are used.
The most commonly used wound dressings are: calcium hydroxide, formocresol (FC), glutaraldehyde, corticosteroids , zinc oxideeugenol cement and ferric sulfate. Although still not used much in clinical practice, mineral trioxide aggregate (MTA) is also described since promising clinical results have been obtained with this material.
Objectives of pulp treatment:
The objectives of pulp treatment are repair and healing of the residual pulp tissue in histological terms and a well-functioning tooth until normal exfoliation. At present, calcium hydroxide is the only dressing that, theoretically, has the potential to fulfill these criteria. Because of the relatively low clinical success rate reported for calcium hydroxide after pulpotomy and because of the restricted lifespan of the primary tooth, less strict criteria for the success of pulp treatment are accepted in many countries. This means that, besides no general harm, no damage should be inflicted to the permanent tooth and the primary tooth should be symptom free until normal exfoliation. Formocresol is considered by many to meet these criteria and, owing to the comparatively high clinical success rate, is still a commonly used dressing material, although healing in histological terms does not occur.
Operative treatment procedures:
Based on clinical and radiographic symptoms and other possible considerations for deciding the best therapy, the following operative treatment options are available :
indirect pulp capping -stepwise excavation
direct pulp capping
Indirect pulp capping- stepwise excavation:
The purpose of stepwise excavation is to prevent pulp exposure by intermittent removal of carious dentin. By comparing the number of pulp exposures from stepwise excavation with those from direct complete excavation, it has been demonstrated both in primary and permanent molars that pulp exposures can often be prevented by stepwise excavation In a systematic review on minimal versus complete caries removal in permanent and Primary teeth it was concluded that partial caries removal is preferable to complete caries removal in deep lesions in order to reduce the risk of carious exposure.
Direct Pulp Capping:
Direct pulp capping means that a minimal pulp exposure is just cleaned and covered with a wound dressing. Except for one study comparing MTA with calcium hydroxide, reported clinical success rates after direct pulp capping in primary teeth are low and the procedure should therefore be restricted to accidental or pinpoint carious exposures. In an RCT on hard-tissue formation after direct pulp capping in healthy young permanent teeth, a calcium hydroxide cement was compared clinically and histologically with a dentin bonding material as wound dressing material. The calcium hydroxide cement was superior in that complete hard-tissue formation occurred more frequently and fewer inflammatory changes were observed.
Indications and contraindications for pulp treatment in primary teeth:
The most important reason for keeping a primary tooth until exfoliation is to preserve the space to prevent crowding in the permanent dentition. Concerning the molars, normally the most important time period is before the first permanent molars have reached occlusion. Other important reasons are to maintain masticatory functions, to prevent tongue habits and to preserve esthetics. Furthermore, it might be important to keep the primary teeth for psychological reasons and the age and/ or mental condition of the child may require special handling and consideration. When the permanent tooth is missing, it may be important to keep the primary tooth.
for an extended period of time. The following conditions generally contradict pulp treatment and the tooth should be extracted:
presence of clinical and/or radiographic symptoms indicating severe inflammatory reactions in the pulp, pulp necrosis, swelling, fistula or abscess.
medically compromised children, particularly those with a lowered resistance to infection.
an unrestorable tooth or less than two-thirds of the root is present.
by: calsmile13
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