Therapeutic approach according to the age of the child and the causative tooth
Part 1. Therapeutics of temporary teeth; Pulp therapy on temporary teeth
Introduction:
- Pulp therapies include techniques to stimulate the potential for dentinopulpal repair (capping), those maintaining healthy radicular pulp (pulpotomy) and those replacing the pulp with intracanal material (pulpectomy).
Our therapeutic choice will be guided by:
- The patient’s general health status (children “at risk”)
- The physiological stage of the temporary tooth and the state of the surrounding periodontium (peri- or interradicular involvement);
- The overall condition of the oral cavity
- Child cooperation and motivation
The prognosis depends on the pulp condition and the proper implementation of pulp and restorative treatments. The failure of conservative pulp treatments is often linked to the loss of sealing of coronal restorations while the dentin is very permeable.
Before deciding not to keep a temporary tooth, it is necessary to take into account the fact that its premature loss can lead to significant after-effects such as:
- Loss of arch length
- Loss of space for permanent tooth to erupt
- Ectopic eruption on inclusion of premolars
- Mesial drift of the first molar
- Extrusion of the antagonist tooth
- Deviation of the interincisal line
- Appearance of para functions
1- Indirect pulp capping:
- Indirect pulp capping is the procedure which consists, after curettage of the carious lesion, in applying a material in contact with often hard dentin. A selective curettage strategy should be preferred, leaving in situ a part of demineralized dentin
Objective :
The goal of indirect pulp capping is to maintain pulp vitality by:
- Stopping the development of caries
- Preserving sclerotic dentin
- Stimulating the formation of tertiary dentin
- Remineralizing decalcified dentin
Indication:
- Indirect pulp capping is recommended for teeth with a deep carious lesion, close to the pulp and without signs of irreversible inflammation or necrosis.
- Young pulps ( stage I and beginning of stage II)
2. Direct pulp capping:
Direct capping is the procedure of applying a bioactive material in direct contact with the pulp wound followed by placement of a coronal restorative material, with the aim of promoting pulp repair and obliteration by a newly formed mineralized barrier.
Indication:
- Direct pulp capping of a temporary tooth remains an exceptional technique and is only indicated on a healthy tooth whose pulp is accidentally exposed in a very specific manner.
Specific contraindications :
- Too much exposure
- Exposure too old with exposure to saliva (> 6 hours).
- Difficulty in ensuring tooth isolation during production
- Difficult to monitor
- Non-cooperation from the child or those around him
Principle:
- The technique involves placing a capping biomaterial directly on the pulp tissue and involves a pulp defense reaction and the formation of reactive dentin.
- The biomaterial (calcium hydroxide or MTA) is deposited on the small diameter and healthy pulp exposure, in order to stimulate the formation of dentin
The prognosis is conditioned by the sealing of the coronal restoration and good asepsis (operative field).
Despite these precautions, the prognosis for direct pulp capping of a temporary tooth is poor. This is explained by the fact that the mesenchymal cells differentiate into odontoclasts leading to internal resorptions.
Direct capping is used less and less since partial pulpotomy shows a better prognosis.
3. Partial pulpotomy:
Partial pulpotomy involves the surgical excision of a small portion of the superficial cameral pulp, followed by the application of a bioactive material in contact with the residual pulp and the placement of a standard coronal restorative material.
It is the therapy of choice for temporary teeth with healthy or partially inflamed pulp.
Principle:
- This technique allows sufficient space to be left for the styling material and provides a watertight seal.
- After performing anesthesia, a small breach is made with a diamond bur at the level of the pulp exposure under irrigation.
- The biomaterial is deposited as before, then a watertight coronal filling is performed.
4. cervical pulpotomy:
- Cervical pulpotomy consists of the extirpation of the entire cameral pulp followed by capping with a biomaterial of the radicular pulp considered healthy.
Directions:
- Asymptomatic tooth
- Pulp inflammation confined to the cameral pulp
- Traumatic or mechanical pulp fractures
- Extensive coronary damage
- Root resorption less than 2/3
Contraindications:
- Health status (cardiopathy at risk of endocarditis, immunosuppression, uncontrolled diabetes, long-term corticosteroid therapy)
- Presence of abscess or fistula
- Pathological mobility
- External or internal resorption
- Periapical or interradicular radiolucency
- Uncontrollable bleeding after complete extirpation of the cameral pulp
5- Pulpectomy:
- This involves the removal of all pulp parenchyma and the obturation of the endodontic system. Pulpectomy is indicated when the pulp presents irreversible inflammation or necrosis of a temporary tooth in stage 2
6. Post-therapeutic control and monitoring of temporary teeth:
- Follow-up with periodic checks until the temporary tooth falls out is necessary; no result that appears correct in the short term should be considered definitively acquired.
- A thorough clinical and radiographic examination of the temporary tooth based on its pathology, the stage of its physiological development and the state of its supporting tissues considerably improves the prognosis of endocanal therapy.
- The teeth thus treated will be subject to regular monitoring (every 6 months) by a careful clinical and radiographic examination in order to detect and interpret any unwanted developments.
The following signs will be looked for:
- The reliability of restoration.
- Appearance of swelling or fistula.
- Accelerated root resorption.
- Appearance or development of inter-radicular resorption.
- Installation of ankylosis.
- Delayed root resorption.
- Follicular or pericoronary inflammation of the underlying tooth.
- Deviation of the underlying tooth germ.
- Persistence of filling paste after root resorption.
Therapeutic approach according to the age of the child and the causative tooth
Therapeutic approach according to the age of the child and the causative tooth
| Physiological stage | Pathology | Treatment |
| Stage I of formation and maturation of the temporary tooth | Trauma Pulp damage (baby bottle syndrome for example) | Pulpotomy if pulp vitality or pulpectomy Pulpotomy |
| Stage II of stability and physiological maturity | TraumaPulp fracture without pathologyCameral pulp pathology (no prolonged bleeding during pulp removal) | Pulpotomy or pulpectomy Pulpotomy Pulpotomy |
| Physiological stage | Pathology | Treatment |
| Total pulp pathology and necrosis with or without periodontal pathology | Root canal treatment if furcation involvement is mild, otherwise extraction | |
| Stage III of physiological resorption | TraumaPulp fracture without pathologyCameral pulp pathology (no prolonged bleeding during pulp removal) | Extraction Pulpotomy Pulpotomy |
Part 2 : Therapeutics of immature permanent teeth, Apexification and apexogenesis therapy
Introduction :
A permanent tooth present in the arch is said to be immature until the apical cemento-dentin junction is in place.
When a DPI presents a pathological condition, 2 therapies are possible:
- Apexogesis:
- It is the development and physiological formation of the root end of a living tooth treated in the event of pulp exposure, by capping or vital pulpotomy. Pulp damage is reversible and apexogenesis will allow apical closure by deposition of dentin and cementum.
Techniques are offered for:
- Maintain pulp vitality
- Induce the formation of a dentin bridge
- Allow root growth and apical closure
Under the name of apexogenesis are grouped 3 types of intervention:
- Direct pulp capping,
- partial pulpotomy and
- cervical pulpotomy.
Therapeutic approach according to the age of the child and the causative tooth
Indication:
- Trauma or significant caries, resulting in exposure of the pulp
Contraindications:
- Inflammatory or infectious phenomena
- Apexification:
- It is the induction of closure of an immature tooth whose pulp is irreversibly affected, usually by the formation of osteocement or an equivalent hard tissue.
- It is done using two different techniques:
- One called omnibus: It is applied to all cases, whether or not the stage of development of the tooth matches the age of the patient. The result obtained is generally an APICAL BARRIER
- The other one, called gentle, is that of HEITHERSAY, it is more of interest in cases where there is a concordance between the age of the patient and the stage of development of the tooth.
- The result obtained is an ANANOMIC APEX
Conclusion:
The morphological and physiological characteristics of immature temporary and permanent teeth make pediatric endodontics very challenging.
Therapeutic approach according to the age of the child and the causative tooth
Baby teeth need to be taken care of to prevent future problems.
Periodontal disease can cause teeth to loosen.
Removable dentures restore chewing function.
In-office fluoride strengthens tooth enamel.
Yellowed teeth can be treated with professional whitening.
Dental abscesses often require antibiotic treatment.
An electric toothbrush cleans more effectively than a manual toothbrush.