Endodontics of temporary teeth
EDUCATIONAL OBJECTIVES
-Distinguish the anatomical and physiological characteristics of temporary teeth / permanent teeth
-Know the indications and contraindications of endodontic therapies that can be considered for temporary teeth
– Implement and adapt the therapeutic strategy according to the pathology and the stage of development of the dental roots
1- Introduction
Endodontics of temporary teeth is of major importance, it allows the dental organs to be preserved on the arch until their physiological loss.
Diagnosis of the pulp condition before any endodontic therapy in children must be based on a complete clinical examination including a medical anamnesis, dental history, clinical tests and radiological examinations.
2- Particularities of temporary teeth
– Very thin enamel
– Large pulp chamber
– Pulpo-periodontal communications:
– at the level of the pulp floor
– at the root level
– Physiological resorption of roots
– Changes in the apical orifice and root anatomy
– Relations with:
– the inter-radicular and inter-dental alveolar bone
– the germ of the permanent tooth
3- Contraindications of endodontic therapies on temporary teeth
General:
-High-risk heart disease
-Any general pathology likely to be aggravated by the existence of an acute or chronic dental infection
Local order:
-If the crown is not restorable;
-If there is internal resorption;
-If the pulp floor is perforated;
-If physiological or pathological root resorption is very significant (more than two thirds of the root(s)).
4- Reminder of dentino-pulp physiology
It goes through three physiological phases according to Demars:
1/ Growth and development phase during which the crown and root are built, called stage I
2/ Maturation and stability phase: there is complete root formation up to clinically detectable resorption called stage II
3/ Regression phase: physiological resorption; extends from the resorption period to the loss of the tooth called stage III
During these 3 periods defined in relation to root modifications, other parameters change (coronary anatomy, attrition, pulp physiology, periodontal changes).
• It takes 1 year for the temporary tooth to fully form its root.
• Clinically, 3 years +/- 6 months elapse between complete root formation and resorption.
5- Endodontic diagnosis
The anamnesis generally offers little diagnostic information.
Apart from conventional questioning and tests, the practitioner can rely more on visual examination by checking:
• The presence of visible or hidden carious foci, the existence or absence of a history of trauma
• the presence of a fistula → path objectified by a gutta cone and RX
• The presence of an abscess materialized by a vestibular swelling
• The condition of the interdental papilla is often congested, hyperplastic in the case of proximal lesions
and retroalveolar radiography:
• Assess the physiological stage
• Visualize the root morphology, the proximity of the underlying germ, the thickness of the bone separating it from the temporary tooth;
• Objectively identify areas of periapical or interradicular osteolysis
• Possible presence of internal resorption, common in temporary dentition whether or not the tooth has been previously treated
6- Therapeutics
6-1 On a living tooth
6-1-1 Pulpotomy
6-1-1-1 Definition
It involves the removal of all the cameral pulp and capping the healthy radicular pulp with a biomaterial. This is the most common pulp treatment in temporary dentition.
- Indications
– pulp inflammation confined to the cameral pulp,
– carious, traumatic or mechanical pulp fractures,
– significant coronary deterioration, children at high risk of caries,
– asymptomatic teeth, root resorption < 2/3)
- Contraindications
– general contraindications,
-an abscess, a fistula, pathological mobility, pathological internal or external resorption
-periapical or inter-radicular radiolucency, pulp calcifications, uncontrollable hemorrhage after complete extirpation of the cameral pulp.
- Technical
-Pre-op Rx
-Local anesthesia
-Laying the surgical field.
– Complete curettage of the carious lesion + pulp extirpation carried out either with a sharp excavator or a diamond ball bur mounted on a turbine to a thickness of 2 mm
– Placement of a sterile cotton ball impregnated with physiological serum and kept in the cavity for 5 minutes followed by the placement of the capping material,
This pulpotomy can be fixative or non-fixative.
- Pulpotomy with pulp fixation
*Formocresol pulpotomy
After eviction of the cameral pulp, a cotton ball soaked in formocresol is applied to the canal entrances for 5 minutes. A capping material (zoe) is applied to the pulp stumps. Then the tooth is restored with a definitive material. Many studies tend to demonstrate that this product is mutagenic.
* Fixations with other fixatives Glutaraldehyde is an alternative to formocresol but is no longer used.
B- Pulpotomy without pulp fixation
* Eugenol-zinc oxide pulpotomy after amputation of the cameral pulp, zinc oxide paste is deposited at the canal entrances, then the definitive treatment can be carried out with glass ionomer cement, amalgam or a preformed cap.
* Pulpotomy with iron sulfate (20%):
It helps to form or strengthen a blood clot. After pulpotomy of the temporary tooth, a cotton ball soaked in iron sulfate is applied under pressure to the pulp stumps for 5 minutes. Then a zinc oxide-eugenol material is applied against the canal entrances.
*LASER Pulpotomy
There are several ways to combine lasers to perform pulpotomy. Most often, an Erbium laser is used to remove the cavity and open the chamber, followed by a CO2 laser to achieve hemostasis. A capping material is then placed on the pulp stumps.
*Pulpotomy with calcium-containing materials
Pulpotomy with MTA It will be condensed at the level of the canal entrances (4 hours for maximum hardness). Subsequently, definitive treatment is carried out.
Pulpotomy with a dentin substitute based on tricalcium silicate (Biodentine®) : It is applied in contact with the pulp stumps. It is possible to completely fill the cavity with Biodentine® and leave it in place for a few weeks or even months, then remove 3-4 mm for definitive treatment.
Pulpotomy with calcium hydroxide : Its use is very limited. However, in stage I, it is the only product that allows radiculogenesis to be preserved.
6-1-2 pulpectomy
6-1-2-1 Definition
It is the removal of all the pulp parenchyma following an extensive carious lesion or trauma and the obturation of the endodontic system. It is more difficult to achieve in temporary teeth: (Varied canal morphology, physiological resorption, underlying definitive germ)
- Indication
– Presence of irreversible pulp inflammation, in stage or early stage III ;
-Pulpotomy without hemostasis possible after 5 minutes of compression
- Contraindication
-If there are systemic contraindications or if the child is unable to cooperate,
– If the tooth is not restorable,
-pathological internal or external resorptions > 2/3,
– If there is damage to the follicular sac of the underlying germ.
- technical
A- coronary time
The carious lesion is curetted and then a large access cavity is created using a turbine-mounted Zekrya® endodontic bur.
The walls must be divergent in order to adapt to the very marked curvature of the roots. This coronal preparation will have a different shape depending on the tooth treated: temp incisor (triangular); canine (oval); mandibular molar (triangular with a mesial base, or even rectangular); max molar (triangular with a vestibular base, or even rectangular)
- root time
1- Evaluation of the working length
– Using pre-operative radiography: Since the roots of the temporary teeth rhyzalize continuously and asymmetrically, it is advisable to use a reduced working length of 2-3 mm compared to the radiographic apex.
– Using an apex locator
– Using length tables
2- Canal shaping
The roots of temporary teeth, and therefore the canals, are curved. It is therefore advisable to pre-curve the instruments to avoid perforations.
Since resorption is greater in relation to the underlying germ, the internal wall of the roots is more fragile: pre-curved files are therefore used along the external walls of the roots.
* shaping by manual instruments There are two systems used:
– K files : made of stainless steel or NiTi, they are used at increasing diameters, up to 30 or 35, with a clockwise rotation movement of a quarter turn, then a pressure movement while performing the same rotation in an anti-clockwise direction.
– Hedström files, “H” : made of stainless steel or NiTi, used for traction. They are also used at increasing diameters up to diameter 30 or 35.*
*shaping by rotary instruments : two categories:
-Systems using several instruments passed sequentially, of variable taper and diameter, and inducing a progressive shaping of the canal.: ProTaper (Dentsply),;
-Systems operating with a single instrument, with variable taper: WaveOne (Dentsply) and One Shape (MICRO-MEGA).
3- Irrigation solutions
*Sodium hypochlorite is an inexpensive solution, and its antiseptic and bactericidal actions are very effective.
*Chlorhexidine is a suitable irrigating solution, with low toxicity to periapical tissues and persistent antibacterial, antifungal, and antiseptic action. However, it does not dissolve living pulp tissue.
*Physiological saline is non-toxic but has no antibacterial or solvent properties. It is mainly used for final rinsing (after irrigation with an antibacterial solution).
* EDTA (ethylenediaminetetraacetic acid) and citric acid
They are used to eliminate the “smear layer” or dentin smear.
4- Root canal filling
Technique :
the canals are closed with a resorbable material which will prevent interference with the eruption of the underlying germ.
A lentulo on a reducing contra-angle is introduced at the working length – 2mm then activated at slow speed in a clockwise direction.
The filling paste is then thickened and packed onto the pulp floor with a sterile cotton pellet or plugger.
Filling Materials : The ideal filling material for the temporary tooth should have the following properties:
Resorption rate similar to that of the primary tooth root; Non-irritating; Resorbable if projected into the periapex; Antiseptic; Adheres to the root walls; Easy to unfill; Radiopaque; Does not discolor the tooth.
- Zinc oxide eugenol paste : was the first material to be used for temporary tooth fillings
- Calcium hydroxide : its resorption rate is faster than the resorption rate of the root, which creates a new access route for bacteria.
- Calcium Oxide is biocompatible, creates a strong apical plug and penetrates well into dentinal tubules, it is very low radiopaque and the expansive nature of calcium oxide in aqueous media leads to a potential risk of root fracture.
- Iodoform paste It is well tolerated by the surrounding tissues in case of projection in the periapex. It has no effect on the anaerobic bacterial flora.
- On necrotic teeth: trimming and root canal disinfection
6-2-1 Definition
It is a therapy which consists of disinfecting a necrotic tooth by removing endocanal residue and carefully filling the canal system.
- Indication
Temporary tooth in stages I and II affected by pulp necrosis with or without periodontal pathology
6-2-3 Contraindication – Patients at risk; Stage III tooth with pulp necrosis and periodontal pathology
- technical
In the case of a necrotic tooth, the endodontic treatment will be carried out in two stages (coronal and root), with inter-session medication (chlorhexidine gel, calcium hydroxide or antibiotic paste) for 7 to 10 days in order to properly disinfect the tooth.
7- Prescription
- Analgesic prescription of paracetamol can be given depending on the severity of the case and its painful potential
- Antibiotic prescription based on the child’s general condition, the presence of hematoma, bone damage or significant soft tissue lesions
8- Reconstruction of the temporary tooth
For anterior teeth, the palatal access cavity can be restored with a composite. For posterior teeth, several solutions are possible:
1- Glass ionomer cement
Their ease of use and reduced working time are serious advantages in pediatric dentistry, particularly when dealing with uncooperative children.
2- Composite resin
Aesthetic and has excellent mechanical, adhesion and sealing properties when the protocol is properly followed.
3- Preformed pedodontic cap
It is placed on the prepared tooth after filling the access cavity with glass ionomer cement or IRM®. It has the longest lifespan and allows the occlusal and mesio-distal space to be maintained.
9- Post-operative check-up
– Post-operative monitoring is then carried out every two weeks and then every 6 months until the temporary tooth has physiologically fallen out.
-If the child’s caries risk is high, the interval between two check-ups can be reduced.
-Post-operative clinical and radiological control (monitoring of the resorption of the filling paste. If there is apical or inter-radicular pathology, or sinus involvement)
10- Complications of endodontic treatments on temporary teeth
can be of 2 orders:
– Clinical failures: Infection (abscess); Pain; Non-physiological mobility
-Radiological failures: Interradicular radiolucency; Internal resorption; External resorption; Non-existent rhyzalysis ; Poor resorption of the filling material
11- Conclusion
Dentino-pulp treatments of temporary teeth remain an area where there are few certainties, both for each particular case and for certain general questions.
Due to their variable anatomy over time, treatments for temporary teeth will always be carried out according to their physiological stage.
Only those in the maturity phase (stage 2) will be accessible to all therapies.
Pulp capping and pulpectomy are, overall, more rarely performed than pulpotomy, which remains the most appropriate pulp treatment in temporary dentition.
Bibliographies
1- Marysette Folliguet: Prevention of dental caries in children before 3 years old, 2006.
2- French Society of Pediatric Odontology. Recommendations on the prescription of fluorides from birth to adolescence
3- AFSSAPS Update Use of fluoride in the prevention of dental caries before the age of 18 October 2008
4- Chahrazed SELLAF, Fatima Zohra SENOUCI BEREKSI & Fadia HADJ SLIMANE final year dissertation: DESCRIPTIVE STUDY OF STRUCTURAL ENAMEL DEFECTS IN SCHOOL CHILDREN AGED 6 TO 15 YEARS OLD; 2017.
Endodontics of temporary teeth
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