THERAPEUTIC APPROACH ACCORDING TO THE AGE OF THE CHILD AND THE CAUSATIVE TOOTH
Plan :
Introduction :
Several factors are involved in the choice of the therapeutic approach to be carried out: the child’s compliance, the type of tooth (temporary, permanent, anterior or posterior), the child’s age and dental age (physiological stage of the tooth), the individual caries risk (ICR), the depth of the damage and the pulp-dentin condition as well as the general condition of the child.
1. INDIVIDUAL CARIES RISK (ICR)
Assessment of individual caries risk (ICR) involves identifying the following risk factors for the development of carious lesions (Muller-Bolla M et al, RFOP 2012) :
-The interrogation
-clinical examination
-other factors:
IN TEMPORARY DENTURE:
During the interrogation:
-Poor oral health of those around you
-Prolonged breastfeeding beyond 18 months
– Sugary drinks (especially sodas outside of meals)
-Candy (especially in preschool)
-Lack of daily brushing
-Long-term use of sugary medications or medications that reduce saliva flow.
On clinical examination:
– Active carious lesions, whether cavitary or not, particularly at the level of the incisors.
-Plaque visible to the naked eye.
IN MIXED DENTURE:
During the interrogation:
-Daily intake between the three meals and the snack of:
Sugary drinks
Sweet foods
Candy
-Long-term use of sugary medications or medications that reduce saliva flow.
– Absence of twice-daily brushing with fluoride toothpaste greater than 1000 ppm.
AThe clinical examination
– Active carious lesion, cavitary or not, of temporary or permanent teeth
– Plaque visible to the naked eye
Others
-Salivary dosage of mutant streptococci
-Low buffer capacity
There are two categories of RCI:
-weak
-pupil.
The presence of a single caries risk factor classifies the child as having high RCI
A child is an individual potentially at high risk of caries (Andersen2008 J).
The main or only real risk marker is the presence of at least one
“cavity or non-cavity carious lesion” and in particular “active”.
Others, in the presence of:
- plaque visible to the naked eye,
- cracked furrows,
- fixed orthodontic appliance,
- HMI and other enamel defects (structural abnormalities)
The presence of any of these factors also classifies the patient as high RCI.
THERAPEUTIC APPROACH ACCORDING TO THE AGE OF THE CHILD AND THE CAUSATIVE TOOTH
2. CHRONOLOGY AND PHYSIOLOGICAL EVOLUTION OF THE TOOTH
| Eruption | Completed root (after eruption) | Start of rhizalysis | Exfoliation | |
| Incisors | 7-8 months | 2 years 2 1/2 years | 4 years central5 years lateral | 6-8 years old |
| Canines | 16-20 months | 3 years | 8 years old | 11-12 years old |
| 1st molar | 12-18 months | 2 ½ years | 6 years old | 10 years |
| 2nd molar | 20-30 months | 3 years | 7 years old | 11-12 years old |
2.1. CHRONOLOGY AND PHYSIOLOGICAL EVOLUTION OF THE TEMPORARY TOOTH (LIFE CYCLE)
2.1.1. Chronology of eruption of the temporary tooth (table below):
2.1.2. Physiology of temporary teeth (table below):
| STAGE 1 | Growth and root development phase: duration 2 years. |
| STAGE 2 | Stability phase: duration 3 years ± 6 months |
| STAGE 3 | Resorption phase: duration 4 years. |
Physiological evolution and biological reactions of the pulp:
| STAGE 1 | immaturity | the temporary tooth has a physiological behavior close to that of the immature permanent tooth: the therapies are focused on pulp conservation |
| STAGE 2 | Stability | The activity of the dentinopulpal organ is less intense, but its defense reaction potential remains high |
| STAGE 3 | Resorption | Still possible at the beginning, the defense potential gradually decreases to become almost zero at the end of the stage. The pulp has the appearance of an inflammatory granulation tissue participating in dental resorption. |
Pathophysiology of the temporary tooth (according to Fortier and Dermas-Fremault, 1987)
| Stadium | Physiological behavior | pathologies |
| I immaturity | Activity close to that of the immature permanent tooth. | Caries (rare). Trauma. |
| II stability | Less intense activity. Restorative potential remains high. | Very rapid pulp damage. Frequent periodontal damage. |
| III resorption | The defense potential gradually decreases. | Rapid evolution towards irreversibility. |
2.2. CHRONOLOGY AND PHYSIOLOGICAL STAGES OF THE PERMANENT TOOTH ACCORDING TO THE AGE OF THE CHILD (NOLLA STAGES)
2.2. .1. Stages of physiological development of the permanent tooth According to Nolla , dental development takes place in ten stages:
From the 1st to the 6th formation of the crown;
From the 7th to the 10th , the formation of the root.
Table The tooth erupts on the arch after the root has reached 2/3 of its length (stage 8).
– About 4 years elapse between the eruption of the tooth and its root maturation (stage 10), placement of the JCD.
– When the tooth has reached approximately its final length (stage 9), it will take approximately 3 years for the JCD to settle in (stage 10).
– The absence of apical construction means that the nerve pathways are not compressed during inflammation, which contributes to the absence of pain.
Table : Noalla stages of permanent tooth formation:
THERAPEUTIC APPROACH ACCORDING TO THE AGE OF THE CHILD AND THE CAUSATIVE TOOTH
2.2.2. Physiology and particularities of the immature permanent tooth
At the time of eruption into the oral cavity, the tooth is said to be immature. Amelogenesis is complete , but on the surface, the subsurface layers of post-eruptive enamel are porous and irregular and therefore highly sensitive to chemical-bacterial aggressions of the oral environment.
Enamel maturation is completed over the years.
Unfinished roots with open apex and thin, divergent root walls
These physiological characteristics of the immature permanent tooth make it more susceptible to developing carious lesions , pathologies which can quickly lead to pulp necrosis.
Necrosis of the DPI pulp will cause the root formation process and therefore apical closure to stop, and cause the thickening of the dentinal walls to stop, further increasing the risk of root fracture.
3. THERAPEUTIC APPROACH ACCORDING TO THE AGE OF THE CHILD AND THE CAUSAL TOOTH
3.1. CHILD COMPLIANCE AND THE SYNOPSISTAL APPROACH
First meeting
- Prioritize open questions for parents,
- Make the child talk,
- Respect “intimate distance” and a gradual approach
- Clinical examination proper.
Organization of care
- Take into account the age of the child
- Go from the simplest to the most complicated care
- Distract and praise
- Desensitize: explain the instruments , tell-show-do
THERAPEUTIC APPROACH ACCORDING TO THE AGE OF THE CHILD AND THE CAUSATIVE TOOTH
3.2. PREVENTION
Preventive therapies in temporary dentition begin before birth and continue at birth with what is called primary-primary prevention and correction of harmful habits that mothers have by preparing bottles and tasting and testing the heat of foods before allocation,
Prevention continues with primary prevention focusing on the nature of the nutrition the child receives (diet) and monitoring oral hygiene by limiting sweets and starting tooth brushing early,
Fluoride toothpastes with precise dosages according to the child’s age and their RCI are administered,
On permanent teeth, in the presence of cracked grooves, a sealing of the grooves is carried out, particularly at the level of the 6-year-old teeth.
It is done with composite sealing resin when the coronal height allows the isolation of the tooth.
With age and age and as the child moves into mixed dentition then into permanent dentition and according to needs (the case), the combination of several mineralizing agents with regular monitoring can be introduced in children with high RCI.
3.3. RESTORATIVE DENTISTRY
The restorative material to be used in pediatric dentistry will depend on the therapy performed, which is linked to the child’s degree of cooperation in the chair, but also and above all to the RCI and the age of the child (physiological stage of the tooth).
For example, a carious lesion without symptoms in favor of irreversible pulp damage, in a child who agrees to sit in the chair but is fearful, refusing the contra-angle despite psychological approach sessions; manual dentin curettage with an excavator followed by restoration with CVI (an interim therapeutic restoration (ITR)) whether on a temporary or even permanent tooth), the Hall technique on temporary molars, in the event of deeper lesions, will be performed.
Once the child is cooperative, and depending on the loss of substance present, microdentistry will be performed to treat small lesions (air, abrasion, sonoabrasion, or by the use of micro-burs following the therapeutic gradient) whether on a temporary or permanent tooth.
In the context of micro-dentistry or minimally invasive dentistry, in mixed dentition, on a permanent tooth, we can perform:
A micro-abrasion which consists of removing low intensity colorations of extrinsic or intrinsic origin limited to the superficial layers of the enamel using 18% hydrochloric acid and scouring, applied by a silicone cup up to 10 times on the dental surface and this is repeated in two to 3 sessions,
On lesions limited to the enamel also in permanent teeth, we can use the technique proposed by Icon (resin infiltration):
methacrylate resin-based product, aims to treat in a micro-invasive manner early caries confined to the enamel at the proximal and vestibular level to stop the progression of early caries or enamel defects.
In the presence of deep carious lesions on a permanent tooth, and to limit the risk of pulp invasion, particularly when it is an immature tooth, macro-dentistry is carried out by Partial Caries Removal, or the Stepwise technique, is performed to treat the lesion.
All materials can be used in restorations, while considering the resistance of the material to masticatory forces (composite resin, silver amalgam), loss of substance (moderate or significant) and RCI (high, poor insulation), CVIC (posteriorly) should be preferred; CVIMAR (anteriorly) as a temporization.
Table : Criteria for choosing coronal restorative materials
on temporary teeth
| The material | Selection criteria |
| glass ionomer cements | – Uncooperative patient – High RCI – Operating difficulties – Temporizing |
| Silver amalgam | -High RCI-Difficulty of isolation-Exfoliation of the tooth within the year (stage 3) |
| Composite | -Cooperating child-Possible isolation |
| Prefabricated pedodontic cap (PPC) | -Significant coronal decay-Obtaining the best results over time and when the tooth is not yet at stage 3-Element of a pediatric prosthesis or a space maintainer |
On a temporary molar (temporary tooth) at the beginning of stage 2 for example, a composite resin or CVI restoration will be made to cover with CPP (significant loss of substance), whereas on a tooth at stage 3, a silver amalgam or CVIc restoration will be made (depending on the loss of substance present).
In the presence of high RCI, poor oral hygiene, composite resin is contraindicated until hygiene improves. On the anterior teeth, a CVIMAR will serve as a temporization material.
3.4. ENDODONTICS
3.4. 1. Endodontics on a temporary tooth
Summary table of endodontic therapies on a temporary tooth
| PATHOLOGY | THE STADIUM | THERAPEUTIC |
| -Caries more than 2mm from the pulp cavity -Caries less than 2mm or pulp breakage | STAGE I | -Indirect pulp capping -direct pulp capping -pulpotomy |
| -Caries more than 2 mm of the pulp cavity -Camera lesion -Total pulpitis or pulp necrosis with or without periodontal pathology | STAGE II | -Pulpotomy -Pulpotomy -endodontic treatment plus root canal obturation |
| Cameral pulp lesion – Total pulpitis or pulp necrosis with or without periodontal pathology – Pulp necrosis with periodontal pathology | STAGE III | -pulpotomy -pulpectomy if 2/3 radicular -If less: pulpectomy or avulsion -avulsion |
3.4.2. ENDODONTICS ON AN IMMATURE PERMANENT TOOTH
3.4.2.1. Apexogenesis therapies
Maintaining vitality is important for continued root formation (apexogenesis) of the immature tooth, so the priority is to keep the immature permanent tooth with vital pulp.
Thus, in the presence of reversible pulp symptoms on this tooth, apexogenesis therapies are indicated.
Apexogenesis therapies are:
capping therapies (dentin, indirect pulp, direct) and pulpotomies.
| Direct pulp capping | Partial Pulpotomy | Cervical pulpotomy | |
| Indications | Pulp exposure without inflammation | Inflammation confined to 2-3 mm on the surface of the pulp tissue | Inflammation of the entire cameral pulp tissue |
| Contraindications |
Lucile Goupy, Chantal Naulin-Ifi, Corinne Tardieu, 2014
Direct pulp capping, which consists of only decontaminating the superficial pulp tissue, has a prognosis of 71 to 88% according to clinical studies when performed under a good operating field and respecting the conditions of its indication.
Partial or cervical pulpotomies are techniques based on the principle of eliminating the inflamed or degenerating cameral pulp and allow for capping of the healthy cameral (partial pulpotomy) or radicular (cervical pulpotomy) pulp.
The operative difficulty lies in determining the state of pulp health
This inflammatory tissue must be removed before the placement of the capping material. The longer the contamination time, the greater the inflammation within the pulp chamber.
Clinical procedures in case of dental fracture exposing the pulp in immature permanent teeth
The techniques used are direct capping, partial pulpotomy (also called Cvek pulpotomy) and cervical pulpotomy,
They are conditioned by the size of the pulp exposure and the time elapsed between the time of the trauma and the consultation. As soon as the pulp is exposed in the oral cavity, the contamination causes an inflammatory defense reaction.
Partial pulpotomy is preferred over direct capping because it provides better control of the exposed surface, eliminates extrapulpal clot, provides better retention of the capping material, allows for more effective sealing, and thus prevents bacterial invasion.
It is also preferred over cervical pulpotomy because it clinically allows pulp sensitivity testing…
Nb : Concerning the mature permanent tooth:
In the case of pulp exposure, endodontic treatment is preferable. However, cervical pulpotomy (with Biodentine or MTA) can be performed if the exposure is not significant and the tooth is restorable (when there is no need for root posts) in a young person or young adult (Naulin-IfI. C, 2016).
3.4.2.2. Pulpectomy or endodontic treatment of immature permanent teeth:
Directions:
-Irreversible pulpitis (indication for pulpectomy)
-Clinical and radiographic signs of pulp necrosis (indication for root canal disinfection treatment)
-Medical indications (contraindication of styling)
Because the tooth is immature, radiculogenesis is not complete.
Root canal obturation cannot be performed until there is an apical barrier (apical constriction)
To allow the continuation of the edification in a therapeutic manner or at least to form an apical barrier, apexification therapy is carried out or even better, currently by stimulating the formation of periodontal tissues (cementum and/or bone) to form this barrier or root elongation by revascularization therapy.
3.4.2.2.1. Revascularization therapy
Objective:
Regenerate the pulp-dentin complex of a necrotic immature permanent tooth in order to make its radiculogenesis (apexogenesis) possible.
Indications
Necrotic immature permanent teeth in healthy children,
Biologically, it is impossible to define the exact nature of the tissue:
-some authors have reported apical closure and thickening of the canal walls which would suggest dentino-genetic capacities close to the pulp;
– others consider it to be just ordinary connective tissue.
Nb: In case of failure, the apexification technique must be implemented.
3.4.2.2.2. Apexification
Objective
To obtain an apical barrier to allow conventional endodontic obturation of a necrotic immature permanent tooth (IPT).
Indication :
Pulp necrosis of an immature permanent tooth with or without periapical involvement
Contraindication:
Compromised medical condition
1. Apexification by apical barrier
Objective
Induce the construction of a physiological apical barrier
2. Apexification by apical plug
Objective
Create an apical barrier by placing a waterproof plug of ProRoot MTA (or Biodentine) in 1 session. Apical closure by hard tissue is carried out later, directly in contact with the material.
Conclusion
So, we will decide:
- Preventive therapy to be carried out according to the child’s level of cooperation, the RCI and the child’s age.
- Restoration material to be used , depending on:
RCI, tooth life stage: remaining time of the physiological stage for the tooth on the arch (temporary tooth life cycle stage), tooth type (anterior or posterior tooth);
- Endodontic therapy to be carried out , depending on the child’s level of cooperation, the physiological stage of the tooth and/or the stage of the life cycle concerning the temporary tooth, the level of root maturation (immature permanent tooth), the pulpo-dentin state of the tooth, the general state (presence or absence of general contraindication).
THERAPEUTIC APPROACH ACCORDING TO THE AGE OF THE CHILD AND THE CAUSATIVE TOOTH
- Bibliography:
- BAUCHAMP et al.Evidence -based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific AffairsJADA.2008
- Michele Muller Bolla, Hélène Blanc, Alexandra Repetto, Tsipora Amsellem et al. Sealing of grooves of permanent molars In College of Pediatric Dentistry Teachers. Practical sheets of pediatric dentistry. Clinical guide. CdP edition, 2014.
- College of teachers in pediatric dentistry coordination M. MULLER-BOLLA . .Endodontics of temporary teeth, Practical sheets of pediatric dentistry, Edition CdP, 2014.
- American Academy of Pediatric Dentistry.Guidelines on pulp therapy for primary and immature permanent teeth. AAPD, 2008 (http://WWW.aapd.org/media:polices-guidelines/g – pulp.pdf) .
- Elkhadem A, Nagi P .Effectiveness of MTA PULPOTOMY IN PRIMARY MOLARS/ A CRITICAL ASSESSMENT OF RELEVANT STUDIES.Evid Based Dent 2013; 14(2):46.
- Nadin G, Goal BR, Yeung A, Glenny AM, pulp.treatment for extensive decay in primary teeth (review).Cochrane Database Syst REV 2003. 1: CD003220.
- Y. Delbos, T. Planes, C. Pilipili. Pulp and pulpo-periodontal pathologies: treatments in temporary dentition; inf dent 2010; 9: 79-86
- M. de La Dure-Molla, C. Naulin-Ifi, C. Eid-Blanchot . Caries and its complications in children, EMC – Oral Medicine Vol 7 n◦5, October 2012
- NAULIN IFI. Endodontic treatments of temporary teeth, clinical realities vol. 12 n° 1, 2001 pp. 73-82
- Courson F, Muller-Bolla M. Coronal restorations on immature permanent teeth. Encycl Med Chir (Elsevier-Masson SAS, Paris), Oral medicine, 2013, 28-725-F-11.
- Kidd EA .Clinical threshold for carious tissue removal.Dent Clin North Am 2010 54(3): 541-9
- Wang X, Thibodeau B, Trope M, Lin LM, Huang GT . histologic chracterization of regerated tissues in clinical space after the revitalization: revascularization procedure of immature dog teeth ith apical periodontitis.J Endod 2010;36 (1):56-63.
THERAPEUTIC APPROACH ACCORDING TO THE AGE OF THE CHILD AND THE CAUSATIVE TOOTH
Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.