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  1. 1. SCHOOL OF DENTISTRY PAEDIATRIC DENTISTRY PULP TREATMENT FOR PRIMARY MOLAR TEETH 1. INTRODUCTION Pulpal involvement of primary molar teeth in the caries-susceptible child occurs relatively frequently, when compared to the permanent dentition. This is due to the small size of the teeth, relatively large pulp chambers, rapid caries progression and, sometimes, failure to diagnose and treat caries early and appropriately. Pulp treatment may be necessary in the following circumstances: • pulpal exposure due to - caries, - iatrogenic exposure during cavity preparation, - fracture of the crown (unusual in primary molars); • non-vital teeth - heavily restored teeth may become non-vital in the absence of a diagnosed pulpal exposure; they present with pain and/or the presence of a swelling or sinus (in primary molars this is often a discrete fluctuant swelling on the buccal attached gingiva, close to the gingival margin, overlying the interradicular region rather than the root apices). Extraction of the tooth may be a more appropriate treatment option in some circumstances. It is not acceptable to keep such teeth under observation until they exfoliate, nor to restore them without carrying out adequate pulp therapy. Such action carries the risk of: • further pain; • infection; • interference with development of the underlying permanent premolar (resulting in the formation of a hypoplastic or Turner tooth). 1.1. Differences between primary and permanent dentition pulp treatment C:lecpulp
  2. 2. Conventional root canal therapy techniques cannot be used in primary teeth because: • roots are variable in number, widely divergent and curved; • root canals are ribbon-shaped and have many interconnections; • roots undergo physiological resorption prior to exfoliation, so root morphology changes with age and resorbable filling materials must be used; • the developing permanent successor is potentially vulnerable to damage if canals are instrumented beyond the apices; • small mouths mean that access is restricted. 2. INDICATIONS Pulp therapy is usually indicated in preference to extraction in the following circumstances: Cooperation: good cooperation with dental treatment or moderately good cooperation when it is considered that extraction would be more difficult for the child than restoring the tooth. Avoiding general anaesthesia: pulp therapy and restorations may be achieved without GA in some children who would require GA for extractions. Medical reasons: (a) haemophilia or other bleeding disorders when it is preferable to avoid extraction and restore the tooth until it exfoliates naturally. (b) some conditions where general anaesthesia is contraindicated (but see also pulp therapy contraindications below). Age of the patient: where the tooth will have a useful working life e.g. a primary second molar restored in a 6-year-old will last approx. 6 years, but in an 11-year-old would be of less benefit; assess by dental age of child and radiographic extent of root resorption. Space maintenance: where the tooth is required to be retained as a natural space maintainer (consider degree of crowding, age of the patient, etc.). Missing permanent successor: in the absence of the permanent premolar, pulp treatment techniques with a good success rate may be appropriate, but also consider extraction and controlled space closure. 3. CONTRAINDICATIONS C:lecpulp
  3. 3. Poor cooperation: unless this can be changed by behaviour management or use of relative analgesia. Poor motivation: including difficulty attending appointments (when 2-visit techniques would be inadvisable), or repeated failure to comply with preventive advice (such that the patient remains at high risk of caries). Multiple grossly carious teeth: where multiple extractions with consideration of balancing and/or compensating extractions would be more appropriate. Medical reasons: (a) congenital heart disease or history of rheumatic fever - primary dentition techniques cannot be guaranteed to eliminate the possible source of bacteraemia, so it is generally agreed that they should not be carried out for these patients even under antibiotic cover; extractions under AB cover are a safer alternative. (b) immunosuppression e.g. leukaemia and other malignant diseases - poor resistance to infection may lead to poor healing and reduced success of these techniques, plus a chronic infection from a failed pulp treatment might put an immunosuppressed child at risk of systemic illness; extractions are often preferable. Unrestorable tooth: where the tooth could not subsequently be restored to function. Severe pain or infection: where extraction would be a quicker and more predictable solution. Space management: where there is little to gain by retaining the tooth e.g. in uncrowded arches, or previous unbalanced extractions, or the permanent successor is due to erupt soon. Advanced root resorption: either physiological as the tooth nears exfoliation, or pathological. 4. TECHNIQUES AND MEDICAMENTS Summary of techniques to be discussed: 4.1. FOR THE VITAL PULP 4.1.1. Pulp capping 4.1.2. Vital pulpotomy * 4.1.3. Devitalisation pulpotomy 4.2. FOR THE NON-VITAL PULP 4.2.1. Non-vital pulpotomy * C:lecpulp
  4. 4. 4.2.2. Pulpectomy *most important techniques in primary molars 4.1. FOR THE VITAL PULP 4.1.1. Pulp capping Indications: - very small exposure of bleeding pulp; - no previous symptoms; - surrounding dentine caries-free. Rationale: - aim to maintain pulp vitality. Technique: - local analgesia has been given and the tooth isolated from saliva contamination; - small exposure has occurred traumatically or following complete caries removal; - cover exposure with hard-setting calcium hydroxide e.g. Dycal or Life; - seal the tooth with an appropriate restoration; - review to ensure no symptoms develop. Medicament: - hard-setting calcium hydroxide e.g. Dycal or Life. Success rate: - moderate, up to 75% (but poor if the strict criteria above are not applied). Summary: - rarely indicated in primary molars as vital pulpotomy is usually favoured as it has such a high success rate and less risk of future pain. 4.1.2. Vital pulpotomy (5 minute formocresol pulpotomy) Indications: - carious or traumatic exposure of bleeding pulp; - no previous symptoms, or symptoms of reversible pulpitis; C:lecpulp
  5. 5. - no clinical or radiographic signs of infection. Rationale: - aim to remove the coronal pulp including all inflamed tissue, leaving the vital radicular pulp which is then fixed with formocresol; the most apical part of the radicular pulp probably remains vital and unaltered. Technique: - local analgesia has been given and the tooth isolated from saliva contamination; - pulpal exposure has occurred traumatically or following complete caries removal; - remove roof of pulp chamber to obtain good access; - remove coronal pulp with a sterile excavator or slow- running large round steel bur, amputating the pulp at the entrance to the root canals; - irrigate; control bleeding with damp cotton wool pledgets; dry; - moisten a cotton wool pledget with formocresol, squeeze off the excess and apply to the pulp stumps for 5 minutes; the pulp stumps should appear blackened when fixed (although this is not such a consistent finding now that dilute formocresol is used); - remove cotton wool pledget and immediately place a soft mix of zinc oxide- eugenol (e.g. Kalzinol) over the pulp stumps without pressure, and seal the tooth with an appropriate restoration. Medicament: - formocresol solution Formalin 19ml Cresol 35ml Glycerin 25ml Water 21ml - a 1 in 5 dilution of the original formula is now recommended and has been shown to be equally effective; C:lecpulp
  6. 6. - in the past it was recommended that a drop of formocresol should be included when mixing the Kalzinol lining, but this is not now done, due to concerns over possible systemic uptake and toxicity; if used as recommended above, it is not thought to present a health hazard; - possible alternative medicaments (a) glutaraldehyde - similar success rate reported, but also toxic; (b) calcium hydroxide - but unacceptable incidence of internal resorption in primary molars treated this way. Success rate: - highly successful, 85-100% after 3 to 5 years (many studies). Summary: - a predictably successful technique, the treatment of choice. 4.1.3. Devitalisation pulpotomy Indications: - as for vital pulpotomy, but when inadequate analgesia or cooperation does not permit removal of the coronal pulp at the first visit. Rationale: - at the first visit a dressing is placed for 1-2 weeks to fix the entire pulp; at the second visit, the tooth has been rendered non-vital so local analgesia is not required to complete the procedure. Technique: - a 2-visit technique; (a) First visit: - local analgesia has been given and the tooth isolated from saliva contamination; - pulpal exposure has occurred traumatically or following complete caries removal; - enlarge exposure as much as possible; - apply paraformaldehyde paste to the exposure site and seal the tooth with a temporary dressing without pressure; (b) Second visit (1-2 weeks later): C:lecpulp
  7. 7. - isolate the tooth from saliva contamination; local analgesia is not required; - remove the dressing and paraformaldehyde paste; - the pulp should no longer be bleeding nor sensitive; - remove roof of pulp chamber to obtain good access; - remove the fixed coronal pulp with a sterile excavator, amputating the pulp at the entrance to the root canals; - irrigate and dry the pulp chamber; - place a soft mix of zinc oxide-eugenol (e.g. Kalzinol) over the pulp stumps without pressure, and seal the tooth with an appropriate restoration. Medicament: - paraformaldehyde paste Paraformaldehyde 1.0g Lignocaine 0.06g Carmine 0.01g Carbowax 1.3g Propylene glycol 0.5ml Success rate: - moderate, 77% after 3 years (Hobson, 1970). Summary: - with careful treatment planning and correct use of local analgesia, you should rarely find this technique necessary. 4.2. FOR THE NON-VITAL PULP 4.2.1. Non-vital pulpotomy Indications: - exposure of a non-bleeding pulp, or severely hyperaemic pulp; - symptoms or signs of irreversible pulpitis, periapical periodontitis or acute abscess e.g. spontaneous pain, pathological mobility, localised fluctuant swelling, interradicular radiolucency; C:lecpulp
  8. 8. - not severe infection with facial swelling. Rationale: - aim to remove accessible pulpal remnants, disinfect remaining necrotic pulp remnants, obturate and seal. Technique: - a 2-visit technique; (a) First visit: - local analgesia may be required as some partly vital pulp may be present; - the tooth is isolated from saliva contamination; - remove roof of pulp chamber to obtain good access; - remove accessible necrotic pulp remnants from pulp chamber and entrances to root canals with hand instruments; irrigate and dry; - moisten a cotton wool pledget with beechwood creosote (or other antiseptic liquid), squeeze off the excess and seal in pulp chamber with a temporary dressing. (a) Second visit (1-2 weeks later): - if resolution of signs and symptoms, complete the procedure as below; if symptoms persist, consider redressing as at previous visit or extract; - isolate the tooth from saliva contamination; local analgesia is not required; - remove the dressing and cotton wool pledget; - place a soft mix of zinc oxide-eugenol (e.g. Kalzinol) in the pulp chamber and press firmly into the entrances to the root canals (compare with vital pulpotomy) and seal the tooth with an appropriate restoration. Medicament: - beechwood creosote Cresol 13% Guaicol 47% C:lecpulp
  9. 9. Other phenols 40% - possible alternative medicaments: formocresol or camphorated paramonochloro-phenol. Success rate: - moderate, 66% after 3 years (Hobson, 1970). Summary: - the recommended technique for non- vital primary molars. 4.2.2. Pulpectomy Indications: - as for non-vital pulpotomy; - excellent patient cooperation essential. Rationale: - aim to remove coronal and radicular pulp remnants, obturate and seal. Technique: - similar to permanent dentition root canal treatment, with some modifications; - particular care is needed to avoid instrumentation beyond the apices, risking damage to the permanent successor; - a resorbable paste must be used for obturation e.g. a slurry of pure zinc oxide- eugenol. Success rate: - very good, over 90%, but very dependent on operator skill and patient cooperation. Summary: - but non-vital pulpotomy is recommended for non-vital primary molars rather than pulpectomy, because pulpectomy carries greater risk of complications, especially in inexperienced hands. 5. RESTORING THE TOOTH C:lecpulp
  10. 10. Pulp treated primary molar teeth should ideally be restored with a stainless steel crown because: • they are often severely broken down by caries; • they are more brittle following removal of the pulp and tooth tissue to gain access; • this type of restoration is less likely to fail than other materials so provides a predictable coronal seal. 6. FOLLOW-UP Pulp treated primary molar teeth should be examined carefully at each recall visit and radiographically at intervals. Pain, swelling, sinus, pathological mobility and interradicular radiolucency are signs of failure. If these occur the situation should be reassessed to decide on retreatment or extraction. The eruption of the permanent successor should be monitored carefully. 7. POTENTIAL COMPLICATIONS 7.1. Failure to exfoliate Exfoliation of pulp treated primary molars may on occasions be delayed, resulting in deflection of the erupting permanent successor. If this is observed, the primary molar should be extracted. However, in a study of teeth treated by formocresol pulpotomy, approximately half the teeth resorbed at the same rate as the opposite untreated teeth, and both faster and slower resorption were observed in the remainder. 7.2. Enamel defects of permanent successor Studies of the relationship between primary molar pulp therapy and enamel defects in the permanent successors show conflicting results. It should be remembered that untreated infection can also lead to defects in developing premolars, so it is difficult to determine whether such problems are due to the disease or its treatment. 7.3. Formocresol burns Formocresol is caustic and can cause burns if it comes into contact with skin or oral mucosa. Always re-cap the bottle immediately after use, dampen rather than soak the cotton wool pledget and take care not to touch the patient’s face with contaminated gloves. If contact with skin does occur, wash the C:lecpulp
  11. 11. area with copious soapy water and obtain medical attention if necessary. 7.4. Overpreparation If using a bur to remove the coronal pulp when carrying out a vital pulpotomy, take care not to perforate the floor of the pulp chamber. 8. PRACTICAL POINTS 8.1. Availability of medicaments Formocresol, paraformaldehyde paste and beechwood creosote are sometimes difficult to obtain in general practice. Try contacting your nearest dental school for details of their supplier. 8.2. Committee on Substances Hazardous to Health regulations A COSHH assessment should be completed for the medicaments described. Further reading Andlaw RJ, Rock WP (1996) A Manual of Paediatric Dentistry. 4th edn. Edinburgh, Churchill Livingstone. Chapter 9. Pulp treatment of primary teeth. pp 107-117. • provides a step-by-step account of the procedures described; • illustrated with line-drawings; • includes important references to the scientific literature. Duggal MS, Curzon MEJ, Fayle SA, Pollard MA, Robertson AJ (1995) Restorative Techniques in Paediatric Dentistry: an illustrated guide to the restoration of extensively carious primary teeth. London, Martin Dunitz. Chapter 4. Pulp Therapy for Primary Teeth. • covers vital pulpotomy and pulpectomy techniques; • well illustrated with diagrams, radiographs and probably the best series of colour photographs you will find; • some differences in emphasis from the above teaching, but recommended. C:lecpulp