excellent methods for endo in children

1. Endodontic Treatment For
Children
(Paediatric Endodontics)

2. Aims of Endodontic Therapy
 Removal of infection and chronic
inflammation.
 Relief of associated pain.
 Maintenance of arch length.
• Important for good masticatory function.
• Future eruption of the permanent dentition with
optimal development of the occlusion.

3. Pre-operative Assessment
 General health of the child, i.e. medical
conditions.
 Attitude of the parent and child.
 Overall assessment of the mouth.
 Assessment of individual tooth.
• Can the tooth be restored if pulp therapy can be performed?
• Does the dental age of the child warrant retention of the
particular tooth?
• Is the pulp status amenable to pulp therapy?

4. Difficulties in Paediatric Endodontics
Apart from limited cooperation:
1. Unable to give accurate details of their symptoms.
2. Responses to clinical tests may be unreliable.
3. In primary teeth:
 Molars have fine tapered roots.
 Accessary canals in the furcational area.
 Close proximity of the developing permanent tooth germ.
4. In young permanent teeth:
 Open apex.

5. Type of Endodontic Treatment
Important factors which determine the type of
endodontic treatment:
1. Exposure – traumatic or carious
2. Vitality – vital or non-vital
3. Apex – open or closed

6. Primary Teeth
Try to avoid premature extraction of primary teeth:
A. To allow the child ‘to eat, speak, smile and grow with them.
B. To prevent limitations of the child diet choices.
C. To prevent exaggeration of any crowding tendencies.
D. Successfully pulp treated primary tooth is a perfect space
maintainer.
Pulp therapy for primary and young permanent teeth has
historically been subject to change and controversy.

7. Diagnosis of Pulpal Pathology

8. Diagnostic Features
 Pain
 Swelling
 Mobility
 Percussion
 Vitality tests
 Radiographs
 Depth of the lesion
 The exposure site
 The amputated pulp stumps

9. Radiographs
 Before starting pulp therapy, one must have a recent radiograph.
 Pulp pathology takes some time to be evident on radiograph.
Pulp Calcifications
• Associated with pulpal degeneration.
• Tooth to be treated as non-vital.
Internal Resorption
• Buccal or lingual resorption may pass undetected.
• Associated with spontaneous pain. Tooth to be treated as non-vital.
• Would indicate failure if occurs after pulp capping or pulpotomy.
External Root Resorption
• Pathological external root resorption indicative of a non-vital pulp.
• Associated with periapical radiolucency.
• Treatment is pulpectomy or extraction.
Bone Resorption
• Radiolucency on radiograph.
• If extensive, extraction.

10. Internal Root Resorption

11. External Root Resorption

12. Treatment techniques
(Primary Teeth)
 Pulp capping
• Indirect pulp capping
• Direct pulp capping
 Pulpotomy
• Vital pulpotomy techniques
• Non-vital pulpotomy technique
or Two-visit disinfectin pulpotomy
or Mortal pulpotomy
 Pulpectomy
(of Non-vital Teeth)

13. Vital Pulpotomy Techniques
(Primary Teeth)
• Using Calcium Hydroxide
• Using Tissue Fixing Medicaments
• Formocresol
• Glutaraldehyde
• N2
• Devitalizing paste
• Using Ferric Sulfate (a Haemostatic Agent)
• Using Cell-Inductive Agents
• MTA
• Biodentine or Bioaggregate
• Bone Morphogenetic Proteins (BMPs)
• Non-Pharmaco-Therapeutic Pulpotomy Techniques
• Electrosurgery
• Lasers

14. Tricalcium Silicate-Based
Cements
(MTA, Biodentine & Bioaggregate)

15. Mineral Trioxide Aggregate
Torabinejad, 1993
A relatively new material:
• Alkaline pH
• Biocompatible
• Prevent bacterial leakage
• Effective in moist environment
• Long setting time (hours)
Uses:
• Pulp Capping (Direct & Indirect in both
Primary & Permanent Teeth)
• Apexogenesis
• Apexification
• Perforations

16. Biodentine (Introduced in 2009)
Biodentine is a contemporary tricalcium silicate based
dentine replacement and repair material.
Properties:
• Alkaline pH
• Biocompatible
• Short setting time (10 – 20 minutes)
• Stronger than MTA
• Easily handled material
• An alternative to MTA
Uses:
• Pulp capping (Direct & Indirect in both
Primary & Permanent Teeth)
• Apexogenesis
• Apexification
• Perforations
• Temporary filling material (because of its strength)

17. PULP CAPPING
The aim of pulp capping is to maintain the vitality
of the pulp by placing a suitable dressing either
directly on the exposed pulp (direct pulp capping)
or on a thin residual layer of slightly soft dentine
(indirect pulp capping).

18. PULP CAPPING
 Indirect pulp capping
 Direct pulp capping

19. Indirect pulp capping
• This treatment is applicable to vital primary and
young permanent teeth with large carious lesions
closely approximating the pulp.
• The aims of treatment are to remove the bulk of
the lesion and to protect the pulp so that it can
repair itself by laying down secondary dentine. In
this way pulp exposure is avoided.
• Medicaments:
• Calcium Hydroxide
• MTA
• Biodentine or Bioaggregate

20. Indirect Pulp Capping
Success rate 76-99%
Indications
• Deep asymptomatic lesion.
• Neglected mouths with numerous cavities.

21. Advantages
 Decay process arrested or slowed down
– gives the pulp chance to repair.
 Bacterial content of the mouth is remarkably
reduced.
 Gives time for preventive programme and the
assessment of patient response.
 Mouth is restored to function and the threat of
dental pain reduced.
 Pulp exposure is avoided.

22. Contra-indications
 Spontaneous pain – pain at night
 Swelling
 Fistula
 Tenderness to percussion
 Pathological mobility
 External root resorption
 Internal root resorption
 Periapical or inter-radicular radiolucency
 Pulp calcifications

23. Technique of Indirect Pulp Capping
Can be performed as a single or two-visit procedure depending upon the experience of the
dentist. Success less predictable in primary than permanent teeth
First Visit
After anaesthesia & isolation, carefully
remove the superficial carious dentine
avoiding pulpal exposure
Prepare cavity making cavity walls
free from caries
Dress the deeper layer of softened
dentine with calcium hydroxide or
MTA or biodentine
Seal the cavity with zinc oxide eugenol
cement
Second Visit
After 6 weeks, re-open the tooth
(should be symptomless)
Arrested carious lesion appear
dark brown in colour & hard
Remove the remaining carious
dentine (secondary dentine
formed on pulpal aspect)
Give sub-lining of calcium
hydroxide cement
Give lining
Restore the tooth

24. Direct Pulp Capping
It is the application of a therapeutic
material to an exposed vital pulp to
induce calcific repair.
Medicaments:
• Calcium Hydroxide
• MTA
• Biodentine or Bioaggregate
• Bone Morphogenetic Proteins (BMPs)

25. Direct Pulp Capping
Indications:
1. Mechanical exposures less than 1sq mm
surrounded by clean dentine in asymptomatic
vital primary teeth.
2. Mechanical or carious exposures less than 1sq
mm in asymptomatic vital young permanent
teeth.

26. Contra-indications
 Spontaneous pain – pain at night
 Swelling
 Fistula
 Tenderness to percussion
 Pathological mobility
 External root resorption
 Internal root resorption
 Periapical or inter-radicular radiolucency
 Pulp calcifications
 Mechanical exposures where an instrument has been
pushed inadvertently into the pulp
 Profuse haemorrhage from the exposure site
 Pus or exudates at the exposure site or very large
exposure

27. Technique of Direct Pulp Capping
Give local anaesthesia & isolate the tooth
Thoroughly wash the exposed surface
(no use of antiseptics)
Prepare a retentive cavity
Dress the exposed pulp with calcium hydroxide
Flow a thin mix of zinc oxide eugenol cement over
the area & allow to set to avoid pressure on the
exposure site
Restore the tooth

28. Complications
Slow onset of pulpal necrosis requiring
further endodontic treatment.

29. Avoid direct pulp capping in primary
teeth
Because:
1. The ideal conditions demanded for success will rarely
occur.
2. The application of calcium hydroxide directly to the
pulps of primary teeth generally initiates a process of
internal resorption.
3. The alternate formocresol pulpotomy enjoys a high rate
of success.

30. Pulpotomy
The removal of coronal pulp and
treatment of radicular pulp.
Vital Pulpotomy
The removal of vital
(inflamed) coronal pulp
tissue, and placement of a
dressing (medicament)
over the cut radicular
pulp stumps to promote
healing or fixation of
tissue in the canals.
Non-vital Pulpotomy
The removal of non-vital
(infected) coronal pulp
tissue and treatment of
the non-vital pulp tissue
in the canals
pharmacologically.

31. Vital Pulpotomy techniques

32. Calcium Hydroxide Pulpotomy
Success rate 50-64% in some studies while in others 12-33%

33. Technique for Calcium Hydroxide
Pulpotomy
Open the pulp chamber & remove pulp
using a sharp excavator or bur
Irrigate the pulp chamber and stumps
with sterile water or saline
Apply sterile cotton pledget to radicular
pulp tissue to achieve haemostasis
Apply calcium hydroxide paste or cement over the
pulp stumps & floor of cavity
Give a lining of thinly mixed zinc oxide
eugenol cement to avoid pressure
Restore the tooth permanently

34. Primary teeth with their abundant blood supply
show a more typical inflammatory response than
that seen in permanent mature teeth. The
exaggerated inflammatory response in primary
teeth account for increased internal and external
root resorption from calcium hydroxide
pulpotomies.

35. Formocresol
 Formalin (formaldehyde) 37% 19ml
 Tricresol (cresol) 35ml
 Glycerin 25ml
 Water 21ml

36. Single-visit Formocresol Pulpotomy
Success rate 98%
Indications:
• Carious or mechanical exposures in vital
primary teeth.

37. Contra-indications
 Spontaneous pain – pain at night
 Swelling
 Fistula
 Tenderness to percussion
 Pathological mobility
 External root resorption
 Internal root resorption
 Periapical or inter-radicular radiolucency
 Pulp calcifications
 Pathological external root resorption
 Pus or serous exudate at the exposure site
 Uncontrollable haemorrhage from the amputated pulp
stumps

38. Technique
Open pulp chamber
Remove pulp from pulp chamber
Arrest haemorrhage
Apply formocresol to pulp stumps
on pledget of cotton wool for 5 min
Place zinc-oxide eugenol paste in the
floor of the pulp chamber
Give lining
Restore the tooth

39. Variations in Technique
 Time of formocresol application
 Dilution of formocresol
 Omission of formocresol from sub-base

40. Concerns Regarding Formocresol
 Local toxicity
 Systemic toxicity
 Carcinogenicity and mutagenicity

41. Diagrammatic Representation of
Completed Pulpotomy
Amalgam
Cement
Zinc-oxide Eugenol Paste
Vital pulp

42. Glutaraldehyde Pulpotomy
Suggested by S- Gravenmade in 1975
Success rate about 96%

43. Advantages
 Equally effective
 More effective tissue fixation of the
coronal portion
 More vital tissue remaining in the apical
portion of the canal
 No dystrophic pulp calcifications

44. Disadvantage
The solution shelf-life is only one week.

45. Technique
Open pulp chamber
Remove pulp from pulp chamber
Arrest haemorrhage
Apply Glutaraldehyde 2% to pulp stumps
on pledget of cotton wool for 3 min
Place zinc-oxide eugenol paste in the
floor of the pulp chamber
Give lining
Restore the tooth

46. N2 Pulpotomy
One- stage pulpotomy procedure
Success rate claimed 98%

47. Two-visit Devitalizing Pulpotomy
(Hobson 1970)
Indications:
• Where it is not possible to obtain satisfactory
anaesthesia of an exposed vital pulp or the child
does not accept local anaesthesia readily.
• Where, following amputation of the coronal pulp, the
radicular stumps continue to bleed excessively.
• When the time factor or lack of cooperation from the child
make it difficult to complete a single-visit pulpotomy
procedure.
• When an exposure is encountered at the end of a long visit on
a young child, who is becoming restless.

48. Contra-indications
 Prolonged bouts of spontaneous pain.
 Evidence of periapical infection.
 Abscess or sinus.
 Wide open apices that may allow the
medicament to escape.

49. Technique
First visit
Place devitalizing paste
over the exposed site
Fill the cavity for 7-10 days
Second visit
Remove devitalized coronal pulp
Wash pulp chamber thoroughly
Rest of the procedure same

50. Ferric Sulfate Pulpotomy
Success rate about 96%
• Used as an alternative to formocresol.
• Ferric Sulfate solutions is used in concentration of
15.5% for 15 seconds.
• Ferric Sulfate when in contact with tissue, forms a
ferric ion-protein complex that mechanically occludes
capillaries at the pulpal amputation site. The subjacent
pulp tissue is then allowed to heal.
• Even though the mechanism of action is still debated,
agglutination of blood proteins results from the reaction
of blood with both the ferric and sulfate ions, and with
the acidic pH of the solution. The agglutinated proteins
form plugs that occlude the capillary orifices.

51. Technique
Open pulp chamber
Remove pulp from pulp chamber
Arrest haemorrhage
Apply ferric sulfate (15.5%) to pulp stumps
on pledget of cotton wool for 15 sec
Flush ferric sulfate from pulp chamber
with copious amount of water
Place zinc-oxide eugenol paste in the
floor of the pulp chamber
Give lining
Restore the tooth

52. Cell Inductive Agents
Pulpotomy
MTA, Biodentine or Bioaggregate, Bone
Morphogenetic Proteins (BMPs)

53. Technique
Open the pulp chamber
Remove pulp completely
Arrest haemorrhage
Apply MTA or Biodentine to
the pulp stump(s)
Give cement lining
Restore the tooth

54. Non-vital Pulpotomy
or
Two-visit Disinfection Pulpotomy
or
Mortal Pulpotomy
Success rate about 66%
Indications:
• Inability to arrest haemorrhage from the
amputated pulp stumps during a single-visit vital
pulpotomy.
• Pus at the exposure site or in the coronal pulp
chamber.
• Non-vital coronal and/or radicular pulp.

55. Pre-operative conditions reducing the
chances of success
 Internal root resorption.
 External pathological root resorption.
 Gross bone loss at the apex or at the
furcation.
 Pus in the pulp chamber.
 Pathological mobility.
 Cellulitis.

56. Technique of Non-vital Pulpotomy
First visit
Open pulp chamber &remove
infected coronal pulp
Irrigate the chamber
Place cotton pellet moistened
with Beechwood Cresote
in the chamber
Seal for 7-10 days
Second visit
Open the tooth (symptomless)
Remove the cotton pellet
Place zinc-oxide eugenol paste
over the floor of the pulp
chamber
Give cement lining
Restore the tooth

57. PULPECTOMY
For partially vital or non-vital teeth
(usually a two stage procedure)
Controversy Regarding Pulpectomy in
Primary Teeth
Main Objections
• Difficulty in preparation of root canals because of complex
and variable morphology.
• Uncertainty related to the effects of instrumentation,
medicaments and root canal filling material on developing
permanent teeth.
• Resorption of root may not always be seen on radiograph
(two dimensional).

58. Pulpectomy Procedure

59. Pulpectomy Procedure
First Visit
Open the pulp chamber
Remove necrotic pulp tissue &
debris from pulp chamber &
irrigate with a suitable antiseptic
solution
Take a working length radiograph
& carryout some root canal
enlargement carefully to avoid root
perforation
Irrigate & dry the pulp chamber &
canals
Apply a disinfectant dressing
(Beechwood Cresote or Kri-liquid)
on cotton pledget
Seal the pulp chamber for 7-10 days
Second Visit
Carryout further root canal
preparation
Irrigate & dry the canals
Place plain Zinc Oxide-
Eugenol paste in the canals
with the help of a pressure
syringe or firmly push the
paste into the root canals
with the help of a cotton
pellet
Give lining of Zinc Oxide-
Eugenol cement
Restore the tooth preferably
with Stainless Steel crown

60. Follow-up of a Pulp Treated Primary
Tooth
Clinical examination – every 6 months
Radiographic examination – every 12-18 months
• Clinical evidence of failure:
• Pain
• Swelling
• Presence of a fistula
• Pathological mobility
• Radiographic evidence of failure:
• Increase in size of radiolucency especially bone loss at
furcation.
• External or internal root resorption.
• Enamel hypoplasia or arrested development of permanent
tooth germ.
• Inflammatory follicular cyst.

61. ENDODONTIC TREATMENT
FOR YOUNG PERMANENT
TEETH
Pulp may be exposed by
• Caries
• Trauma
• Accidental exposure during
cavity preparation

62. Choices of Treatment procedures
(For Young Permanent Teeth)
 Pulp capping.
• Indirect pulp capping
• Direct pulp capping
 Apexogenesis (vital pulpotomy).
 Apexification
• Induction of root end repair using calcium hydroxide.
• Immediate apexification with MTA or Biodentine
apical barrier.
 Revascularization Or Regenerative Endodontic
Technique (RET).

63. Pulp Capping
(already discussed)

64. Apexogenesis
(vital Pulpotomy)
It is the amputation of the coronal pulp
and treatment of the vital pulp stumps
with Calcium hydroxide or MTA or
Biodentine or BMPs.
Aim:
To permit normal apical closure.

65. Indications
 Young permanent teeth with large exposures (where
direct pulp capping is not possible).
 Where the infection or inflammation is confined to the
pulp chamber only.

66. Contra-indications
 Clinical or radiographic evidence of periapical infection.
 Persistent haemorrhage from the amputated pulp stumps.
 Non-vital pulp.
 Pus in the root canals.

67. Technique of Apexogenesis
Open the pulp chamber widely
Remove pulp completely
Arrest haemorrhage
Apply Calcium hydroxide or MTA or Biodentine
or BMPs to the pulp stump(s)
Give cement lining
Restore the tooth

68. Follow-up
 Calcific tissue forms within 6-8 weeks in case of
Calcium hydroxide and immediately with MTA
or Biodentine.
 The tooth should be kept under radiographic
review at 6 monthly, then yearly, intervals.
 Once the apex is closed, conventional root
canal therapy is carried out.

69. Complications
Rarely, pulpal necrosis and
apical infection occur.

70. Partial Pulpotomy
•Partial pulpotomy for cariously exposed
young permanent teeth
•Partial pulpotomy for traumatically exposed
young permanent teeth (Cvek’s pulpotomy)

71. Partial Pulpotomy
• Partial removal of the pulp from pulp chamber
in cariously exposed young permanent teeth.
• Only 1-3 mm or more of the inflamed pulp
tissue beneath an exposure is removed to reach
healthy pulp tissue.
• Covering material is Calcium hydroxide or
MTA or Biodentine followed by filling.

72. Cvek’s Pulpotomy
• Partial pulpotomy for traumatically exposed
young permanent teeth.
• Only 1-3 mm or more of the vital pulp is
removed to reach uninfected pulp or healthy
pulp tissue.
• Covering material is Calcium hydroxide or
MTA or Biodentine followed by filling.

73. Apexification
(Apical Closure)
Treatment options for non-vital permanent
tooth with open apex (blunderbuss canal):
 Root canal therapy followed by apical surgery.
 Induction of root-end repair with Calcium Hydroxide
followed by conventional root canal therapy.
 Immediate apical closure with Mineral Trioxide
Aggregate (MTA) or Biodentine followed by
conventional root canal therapy.

74. Apexification
First choice not recommended because:
• Surgical techniques are to be avoided whenever possible in
young children.
• Very difficult to do retrograde filling as the thin apical walls
do not lend themselves to undercutting.
• Apical surgery further reduce the length of the root which is
already short because of its incomplete formation.
Therefore root-end repair (barrier) induced with Calcium
Hydroxide and immediate apical closure with Mineral Trioxide
Aggregate (MTA) or Biodentine are preferred procedures in
non-vital permanent teeth with open apices.

75. Indication
An immature permanent tooth, usually an
incisor, with an infected root canal and an
incompletely formed apex, where it is
considered important to avoid extraction.

76. Contra-indications
 Medical reasons for avoiding root canal therapy.
 Clinical and radiographic evidence of gross
apical infection and bone loss.

77. Procedure f or Apexification
(with Calcium Hydroxide)
Open the tooth & remove necrotic
tissue from the canal
Take working length radiograph & file
the canal 1-2 mm short of the apex
Irrigate &dry the canal
Fill the canal with calcium hydroxide
Seal the canal

78. Calcium Hydroxide Replacement

79. Follow-up
 Post-operative follow up at 4 - 6 monthly
intervals include:
• An evaluation of signs and symptoms.
• A periapical radiograph for comparison
with the baseline radiograph.
 Two types of apical closure may occur:
• Root growth (cells of epithelial sheath of Hertwig alive).
• Calcific tissue may form at the apex (osteodentine or
cementum).

80. Follow-up (continues)
 Calcific repair completion take 6 – 18 months

81. Failure
Chances of failure will be more if:
 Adjacent tooth is involved.
 Gross bone resorption at apical area.
 Inefficient procedure.
 During reopening of the canal for calcium hydroxide replacement,
your file can damage the partially formed calcific barrier.
 If the root is very short and wide.

82. Procedure f or Apexification
(with MTA or Biodentine)
Open the tooth, carryout debridement
Irrigate with sodium hypochlorite (2.5-5%)
Take radiographic working length with the
carrier (messing gun) placed in the canal
Dry the canal and place MTA or Biodentine with the gun in
the apical portion (upto 3-4mm thickness)
Place a moist cotton wool pledget in the canal and seal the access
cavity in case of MTA while for Biodentine, the procedure
(obturation) may be done in the same visit
On the following day (or next visit) obturate with G.P
(cold lateral condensation or thermoplasticized G.P)

83. Messing Gun

85. Revascularization of Immature Non-Vital
Permanent Teeth OR Regenerative
Endodontic Technique (RET)
 Apexification with Calcium hydroxide – multiple appointments,
long treatment period, Ca (OH)2 alter properties of dentine.
 Apexification with MTA or Biodentine effective – technique
sensitive.
 Apexification with Calcium hydroxide or MTA or Biodentine - all
facilitate 3-dimentional root canal obturation with G.P but the root
remains short with thin radicular walls and susceptible to fracture.
 Therefore, the ideal treatment for an immature non-vital tooth is to
regenerate a healthy pulp-dentine complex that would allow the
continued maturation of the root (Revascularization).

86. Procedure for Revascularization of Young
( Immature) Non-vital Permanent Teeth
Open the tooth & remove necrotic tissue from the
canal without much instrumentation
Irrigate copiously with 5% sodium hypochlorite
& normal saline
Place triple antibiotic paste (ciprofloxacin + metronidazole
+ cefaclor) in the canal for 2-6 weeks
Take periapical radiograph to verify resolution of infection.
Reopen & irrigate the canal with NaOCl & saline
Dry the coronal half of the canal with sterile paper points &
induce bleeding by filing beyond the apex with a sterile file

87. Continues
After reaching cemento-enamel junction, leave the
blood untouched for 15 minutes to form a clot
Place 3mm of MTA barrier over the clot
Cover the MTA with a wet cotton pellet and
seal it temporarily
Reopen & remove the cotton pellet 1-2 days later. Give glass
ionomer cement lining &fill the cavity with composite
Follow up at 1, 2, 3, 6, 12, 18 & 24 months. Take periapical
radiographs at these visits to check for
continued root development.

88. Clinical Complications in the Revascularization
of Immature Non-vital Permanent Teeth
1. Bluish tooth discolouration.
• Replacement of minocycline with cefaclor.
2. Failure to produce significant bleeding.
• Use of local anaesthetic without a vasoconstrictor.
• Use of slightly bent file for over-instrumentation beyond the apex.
• File dipped in a calcium chelator 17% EDTA.
3. Collapse of the MTA material into the canal.
• Place a collagen matrix above the blood clot which serves as a solid
absorbable matrix against which the MTA could be packed.
4. No significant results may be seen before 6 months.
• Tell the parents about lengthy treatment.

89. Modified Formocresol Pulpotomy