Therapeutic approaches according to the age of the child and the causative tooth:
Introduction :
Any pathology (caries, trauma) of the immature tooth forces us to reconsider our conservative therapies according to the stage of root and apical formation.
Our interventions will therefore focus on evolving structures and our primary goal will be to enable dental and alveolar formations to complete their construction.
Conservative therapies:
- Preventive therapy:
Prevention in the strict sense or primary prevention is the set of measures implemented to prevent a disease from taking hold.
When individual prevention is aimed at the child, it is the result of a partnership between three wishes: that of the parents, that of the child and that of the dentist.
Preventive action must focus on several factors:
- Action on food.
- Implementation of appropriate oral hygiene.
- Strengthening teeth by adding fluoride.
- Dental visits and professional preventive acts (sealants).
a). action on the power supply:
All foods that contain carbohydrates are potentially cariogenic.
This means that the majority of food and drink we consume is cariogenic.
It is impossible to eliminate them from our diet, but we can modify certain foods to make them non-cariogenic.
Our action will focus on:
- Limiting food intake.
- Choosing a balanced diet.
- Avoid repeated intake of sugary drinks, or drinks with a low pH.
b). implementation of appropriate oral hygiene:
The aim is to control dental plaque in quantity and quality.
C).Strengthening teeth by providing fluoride: Fluoride is a mineral found in nature and is considered an essential nutrient for the formation of healthy bones and teeth, just like calcium.
It is usually found inside a mineral or organic compound called fluoride.
The three main mechanisms of action of fluoride are:
- Inhibition of demeniralization of early carious lesions and promotion of remineralization with formation of less soluble enamel.
- Inhibition of glycolysis reducing the acidogenic potential of bacteria.
- Reduction of enamel solubility in acids by incorporation of fluoride into hydroxyapatite crystal.
Fluoride can be absorbed in two ways, either topically or systemically:
- Topical mode consists of applying the substance to the external surface of the teeth. (for example: toothpastes, mouthwashes containing fluoride, gels).
- The systemic mode consists of the ingestion of fluoride, which then binds to the tooth during its formation.
d). Professional preventive actions: prophylactic sealing of grooves, pits and fissures “sealants”:
Sealants are composites generally placed in the grooves of the permanent molars in order to protect them, preventing the onset of carious processes.
- Curative therapy: a truly conservative approach begins with diagnosis and assessment of caries risk in order to decide on the most relevant treatments, taking into account the individual status of each patient.
Preserving original dental structures is the priority of modern dentistry, both medical and preventive.
- Endodontic therapies for immature permanent teeth:
Endodontic treatment of immature permanent teeth was considered one of the most challenging problems in endodontics.
- Problems with an open apex:
- very wide canal: complete debridement impossible.
- very large apical opening: drying problems and impossibility of a watertight apical seal (divergent canal walls).
- Thinness of the canal walls: high susceptibility to fracture.
Therapeutic approaches according to the age of the child and the causative tooth
- Etiologies of pulpopathies of immature permanent teeth:
(See previous course)
- Caries:
- Trauma:
Therapeutic approaches according to the age of the child and the causative tooth
- Endodontic treatment of immature permanent teeth:
C.1. Essential prerequisite:
- Questioning: of the patient and his parents to determine the general history and their therapeutic contraindications.
- Clinical examination: to assess pulp vitality, extent of lesion and duration of exposure.
- Radiographic examination: to assess the stage of root development and the extent of the lesion.
C.2. therapeutic means:
- Calcium hydroxide:
- Product presentation:
- Master presentation: calcium hydroxide is used pure, a mixture of Ca(oh)2 powder and an anesthetic solution without vasoconstrictor or better: sterile distilled water.
Properties :
- These preparations maintain a high PH.
- Allow rapid release of OH- ions (antibacterial activity).
Indications:
- Pulp capping.
- Pulpotomy.
- Endodontic treatment of mature and immature permanent teeth.
- Internal and external resorptions.
- Commercial presentation: pastes with varying concentrations, these preparations are packaged in syringes for easy use.
- Mineral trioxide aggregate (MTA):
Consists of two phases: a crystalline phase and an amorphous phase.
- Presentation of the material: initially; a gray powder made up of fine hydrophilic particles to be protected from humidity, subsequently the product was refined by the elimination of certain oxides: obtaining a white product.
MTA is prepared by mixing with sterile water.
(Properties: see 2nd year course : root canal filling materials).
C.3 Pulp therapies for immature permanent teeth:
3.1 Apexogenesis: the immature permanent tooth with living pulp:
- Definition: It is the physiological development and formation of the root end after pulp exposure of an incompletely formed tooth, in which the pulp is alive.
(Andreassen 1990)
- Goals:
- Maintain pulp vitality
- Induce the formation of a dentin bridge
- Allow the pulp, which is neither infected nor inflamed, to continue building the root and apical closure by placing the apical JCD.
- 03 techniques are possible: (direct pulp capping, partial pulpotomy and cervical pulpotomy)
- Direct pulp capping:
- Definition: is an intervention which consists of placing on the exposed dental pulp a substance capable of allowing its healing and the closure of the pulp chamber and also the root formation.
- Indications:
Minor pulp exposure (accidental denudation of the pulp following an iatrogenic dental procedure during curettage or poorly conducted cavity cutting, denudation following penetrating closure).
- Operating protocol:
- Anesthesia
- Setting up the operating field
- Cleaning the pulp wound: sterile physiological serum.
- Hemostasis
- Styling itself: the application of calcium hydroxide or MTA.
- Coronary reconstruction: it must be watertight.
- Post-operative clinical and radiographic follow-up: pulp vitality tests and radiographic checks must be carried out: 1st check : one week later
2nd check – up: 4 weeks (the presence of a dentin bridge can be seen).
Regular checks every 3 months for a period of 1 to 3 years until the JCD is implemented.
- Pulpotomy (partial or cervical):
- Definition: is an intervention which consists of performing at a chosen level, the section of the living cameral pulp, to eliminate the amputated part and to place in contact with the remaining pulp stump(s) a substance capable of allowing at this level its healing and the dentinal closure of the canal orifice(s).
- Indications:
- More extensive pulp exposure.
- Exposure time greater than 24 hours but not exceeding 48 hours for partial pulpotomy.
- Extensive pulp exposure and a time period exceeding 3 days for cervical pulpotomy.
- Operating protocol:
- Preliminary radio.
- Anesthesia with vasoconstrictor.
- Laying the surgical field.
- Cleaning the tooth and pulp wound.
- Amputation of the pulp (partial or cervical depending on the case). The amputation is performed under continuous irrigation of sterile physiological serum
- Hemostasis
- Washing the wound (cotton ball + physiological serum ).
- Setting up the styling product
- Watertight coronal reconstruction.
- Post-operative follow-up:
- Clinically the tests must be positive.
- The calcified bridge re-isolating the pulp should be visible from the 4th week .
- Note: as soon as stage 10 is reached, a pulpectomy must be performed followed by canal obturation if not; risk of dystrophic calcification.
3.2 Apexification: immature permanent tooth with mortified pulp.
- Definition:
It is the induction of apical closure, or resumption of development, of an immature tooth whose pulp is no longer alive, by the formation of osteo-cementum or a comparable tissue. (Breillat 1973).
- Goals:
- Apical closure without root lengthening .
- Apical closure with root elongation when the cells of the Hertwig sheath remain alive.
- Surgical technique:
- Calcium Hydroxide Apexification Technique:
- Operating field
- Endodontic access cavity
- Mechanical trimming (pins + files) + chemical trimming with sodium hypochlorite.
- Radiographic determination of working length/at shortest wall.
- Drying the canal
- Filling the canal with calcium hydroxide.
- X-ray control.
- Provisional coronary reconstruction (CVI).
- Post-operative clinical and radiographic follow-up.
After 6 to 18 months an apical barrier can be obtained.
- Permanent root canal filling.
- Final restoration.
- Apexification with MTA: MTA is used to create an apical plug on teeth with necrotic pulp and an open apex.
- Operating protocol:
- Setting up the operating field.
- Adequate endodontic access cavity
- Root canal debridement + CLONa irrigation
- Drying the canal
- An apical plug with 3 to 4 mm MTA is created and controlled radiographically
- Placing a damp cotton ball in the canal
- Temporary coronal obturation 3 to 4 hours
- Subsequently, perform a canal obturation with gutta for the remaining part.
- Final restoration.
Conclusion :
Current pediatric dentistry is fully equipped to offer our children mouths that are practically free of carious lesions with harmoniously implanted teeth.
Dental crowns are used to restore the shape and function of a damaged tooth.
Bruxism, or teeth grinding, can cause premature wear and often requires wearing a retainer at night.
Dental abscesses are painful infections that require prompt treatment to avoid complications. Gum grafting is a surgical procedure that can treat gum recession. Dentists use composite materials for fillings because they match the natural color of the teeth.
A diet high in sugar increases the risk of developing tooth decay.
Pediatric dental care is essential to establish good hygiene habits from an early age.