26

Pain control and

carious primary teeth
SUMMARY
Paul is 5 years old. He is in pain from one of his upper
back teeth. He has never had any treatment before.
How would you manage Pauls problem?
What questions do you need to ask regarding the pain?
Site ask Paul to point to the tooth.
Severity does the pain stop him from playing or sleeping?
Onset what causes it? Is it in response to hot, cold or sweet
stimuli, or does it occur spontaneously? Does it wake him up
from sleep?
Character is it a sharp pain or is it dull and throbbing?
Duration how long does it last?
The characteristics of the pain of reversible and irrevers-
ible pulpitis are shown in Table 26.1.
An acute and/or spreading infection or swelling may
require the prescription of antibiotics. This is discussed in
Chapter 27. Antibiotics should only be prescribed for pain
in the absence of swelling for immunosuppressed patients.
Analgesics may be necessary for pain (Table 26.2).
Table 26.1 Pain characteristics
Reversible Irreversible
Transient or short duration (minutes) Long duration
Response to hot, cold, sweet Response to pressure (chewing)
Sharp Spontaneous
Doesnt stop play or sleep Throbbing
Stops play or sleep
Table 26.2 Dosages for common paediatric analgesics
Drug Dosage
Paracetamol 20 mg/kg initially then 15 mg/kg every 4 hours
Maximum 24-hour dosage 90 mg/kg
Ensure adequate hydration
Ibuprofen (Non-steroidal anti-
inammatory drug (NSAID))
510 mg/kg every 8 hours
Can be used in conjunction with paracetamol
Best given with food and drink
Fig. 26.1 Caries aecting d and e .
The initial management of a child attending in pain is
often constrained by possible lack of sleep on behalf of the
child or time available to the dentist to treat this extra emer-
gency patient.
What dressings can help manage pulpitis initially?
After gentle excavation of the softest layer of coronal caries:
Zinc oxide eugenol cement (e.g. Kalzinol or Intermediate
Restorative Material (IRM)).
Poly-antibiotic and steroid pastes (e.g. Ledermix) placed
underneath zinc oxide eugenol cement or glass ionomer
cement (GIC).
If a tooth is abscessed, there is often signicant coronal
destruction. The pulp chamber of such teeth can often be
accessed by gentle excavation, and a dressing of Ledermix
on some cotton wool placed within the chamber and sealed
with cement will often lead to resolution of the swelling.
Dressing open cavities has a number of advantages:
Simple introduction to dental procedures.
Oral mutans streptococci count is reduced when excavation
of gross caries is accomplished. If the cavity is then
completely sealed by a GIC there is evidence that the viability
of the remaining organisms decreases and caries progression
is greatly reduced. This buys the dentist time to institute
preventive and behaviour management programmes before
reassessing teeth with temporary restorations.
GIC cements act as a uoride reservoir.
Makes toothbrushing and eating more comfortable.
History
Questioning suggested a reversible pulpitis in the upper left
quadrant but with recent features of an irreversible nature.
Examination
Paul has no extraoral swelling or asymmetry. Intraorally he
has all his primary teeth with the exception of a and a,
which have just exfoliated. 1 and 1 are just erupting. There
is mesial occlusal caries with loss of the marginal ridge on
d . The e is grossly carious (Fig. 26.1). There is no associated
soft tissue swelling.
What investigation is essential to allow you to formulate a
treatment plan?
Bitewing radiographs are necessary to diagnose approximal
caries in primary molars with their wide contact areas.
Radiographs will increase the diagnosed yield of caries by
26 PA I N C O N T R O L A N D C A R I O U S P R I MA R Y T E E T H

114
Treatment
Initial temporization of d and e was with Ledermix paste
under IRM cement. A preventive and behaviour manage-
ment programme was started. e was restored with an adhe-
sive restoration.
What is your defnitive treatment plan for d and e?
Both these teeth require primary molar pulp treatment.
Although d is less affected by caries it has lost its mesial
marginal ridge and will have histological evidence of
inammation in the coronal pulp.
What types of primary molar pulp treatment are there?
Vital pulpotomy. Coronal pulp is removed under local
anaesthesia (LA) and the pulp stumps dressed for 15 seconds
with 15.5% ferric sulphate. The chamber is then lled with
zinc oxide eugenol cement.
Desensitizing pulp therapy. This is a two-stage procedure that is
used when anaesthesia cannot be gained. A pledget of
cotton wool with Ledermix paste is sealed into the cavity/
chamber with temporary cement for 714 days. At the
second visit the pulp can be removed and restored as in a
vital pulpotomy or pulpectomy depending on the clinical
nding.
Pulpectomy. This is used when there is non-vital tissue in the
root canals. The canals are instrumented with les and the
canals lled with either zinc oxide cement or a calcium
hydroxide-iodoform paste.
The decision regarding which type of pulp treatment is
applicable can often only be made once treatment starts and
the clinical ndings are taken into account. Pulp treatment
should, ideally, always be completed under LA (with excep-
tion of desensitizing pulp therapy where LA has either not
worked or cannot be given for behavioural reasons).
The status of formocresol as a pulpotomy medicament.
Formocresol has traditionally been used and widely recog-
nized within the profession as a medium that has delivered
the best long-term results. A one-fth dilution of the origi-
nal Buckleys formulation has been shown to be as effective
as the full strength concentrate. However, Buckleys is not
easy to obtain in the UK, and, in addition, there have been
some international concerns over its toxicity both locally
and systemically. These concerns have grown in the past 5
years with formaldehyde, one of the important components
of formocresol being linked to nasopharyngeal cancer.
Attempts have been ongoing for the past few years to nd
a suitable replacement, and one material that has been
shown in randomized controlled trials to be of equal ef-
cacy for pulpotomies in primary molars is 15.5% ferric sul-
phate. Ferric sulphate has previously been used by the
dental profession as an astringent (available commercially
as Astringedent) to control gingival bleeding prior to
impression taking, and also in endodontics. It is an excellent
haemostatic agent, forming a ferric ionprotein complex on
contact with blood, which then stops further bleeding by
sealing the vessels. However, it must be remembered that
ferric sulphate has no xative effect. For this reason, an
accurate diagnosis of the state of the pulp tissue left behind
and on which ferric sulphate is being applied will need to
be made.
What is the appropriate restorative material after pulp
treatment?
The techniques employed for denitive restorations in
young children should take into account the active nature
of the disease in the young child. The use of adhesive res-
torations should be limited to occlusal and small approxi-
mal cavities. Extensive cavities, teeth with two or more
carious surfaces, and teeth after pulpotomy or pulpectomy
should be restored with stainless steel crowns. Amalgam is
still widely used as a restorative material but adhesive
materials, especially polyacid-modied resins (compom-
ers), and composite resins may be preferred as they have
been shown to be as durable if they are placed under appro-
priate conditions with adequate isolation. Cermet cements
are not appropriate restorations for primary teeth.
Extraction of teeth will be required if they are unrestor-
able or if there is acute pain and infection (Chapter 27). In
pre-school children the extraction of one or two teeth may
be able to be accomplished under LA with oral or inhalation
sedation. However, if extractions are required in two or
more quadrants then general anaesthesia (GA) in an appro-
priate setting will be the best way to accomplish the extrac-
tions. When GA is used in young children, treatment
planning should be radical and aim to prevent a repeat GA
in the future.
When planning extractions it is important to consider the
need for balancing extractions. Factors such as the likeli-
hood of continued future attendance and cooperation of the
child should also be borne in mind. In pre-school children
with extensive caries, extraction of rst primary molars with
maintenance and restoration of second primary molars
where possible is often a good plan. This limits the risk of
further decay by eliminating interproximal contact areas in
the posterior teeth.
Key point
Advantages of dressing open cavities are:
Introduction to dental procedures.
Reduction of Streptococcus mutans count.
GIC acts as a fuoride reservoir.
Eating and toothbrushing are more comfortable.
50%. Frequency of subsequent bitewing radiographs will
depend on the classication of caries risk: high risk patients
should have radiographs 612 monthly; medium risk 1218
monthly; low risk 1824 monthly. In Pauls case a small
amount of occlusal caries was conrmed in e .
Key point
The main types of primary molar pulp treatment are:
Vital pulpotomy.
Desensitizing pulp therapy.
Pulpectomy.
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MI N D MA P 2 6
initial
dressing
zinc oxide eugenol cement
polyantibiotic / steroid and cement
paracetamol
ibuprofen
analgesics
antibiotics (if swelling)
vital pulpotomy
devitalising pulpotomy
pulpectomy
extraction
definitive
Management
site
severity
onset
character
duration
History
pain to hot and cold
reversible
irreversible
pain transient / short duration
pain sharp in nature
pain on chewing
dull ache continuous / long duration
spontaneous pain
Characteristics
Pain Control and Carious Primary Teeth