Management Of Deep Carious Lesions In Children

Presented by Prof. Dr. Nevine Waly Prof. in Pediatric Dentistry and Public Health Department Faculty of Oral and Dental Medicine Cairo University

Pulp exposure is caused most commonly by caries but may also occur during cavity preparation or by fracture of the crown. Pulp exposures caused by caries occur more frequently in primary than in permanent teeth because primary teeth have relatively large pulp chambers, more prominent pulp horns and thinner enamel and dentine. In primary molars with proximal cavities, pulp involvement occurs in about 85% of those with broken marginal ridges.

Diagnostic aids in selection of teeth for vital pulp therapy:

1-History of pain: The dentist should distinguish between two types of pain: provoked and spontaneous pain (unprovoked). Provoked pain: is precipitated by stimulus (thermal, chemical or mechanical) and disappears after removal of stimulus: Pain associated with eating is due to pressure from accumulated food within the carious lesion and chemical irritation to the vital pulp protected by a thin layer of dentine (good prognosis). Pain due to cold food or drinks indicates hyperaemia. Pain due to hot food or drinks indicates pulpitis. Spontaneous pain: is a throbbing constant pain that may keep the patient awake at night. It indicates advanced pulp damage (poor prognosis).

2-Clinical signs and symptoms:

Abnormal tooth mobility indicates severely

diseased pulp or involvement of periodontal ligament. Sensitivity to percussion indicates apical or periodontal inflammation or both. Presence of swelling, sinus, draining fistula or chronic abcess indicates a non vital pulp.

 Size of exposure and amount of pulpal

bleeding are the most valuable observations in diagnosing the condition of the primary pulp:

Small pin-point exposure surrounded by sound dentine indicates favorable pulp condition. Large exposure with watery exudate or pus indicates unfavorable pulp condition. Small controllable amount of bleeding during and or following pulp amputation is a favorable condition for pulp therapy. Excessive uncontrollable bleeding during and or following pulp amputation is an unfavorable condition for pulp therapy.

3-Radiographic interpretation:
Radiographic interpretation in children is
more difficult than adults due to:
Young permanent teeth with incompletely formed root ends give the impression of Periapical radiolucency. The roots of primary molars undergoing normal physiologic resorption may suggest a pathologic change. Permanent teeth are superimposed on the primary teeth.

Radiographs are valuable for determining the following:

Periapical changes such as widening of
periodontal membrane space. Rarefaction in supporting bone. Calcified masses within pulp chamber and root canals. Periapical and interradicular radiolucencies of bone.

4-Vitality tests:
Either thermal or electrical. Thermal pulp vitality tests: Application of heat (hot gutta percha or hot instrument). Application of cold (ethyl chloride or ice cone). The reaction of a normal tooth is tested first (pain disappears after removal of stimulus). If pain persists, this indicates pulpitis. If tooth does not respond, this indicates a nonvital pulp.

Electric pulp tester: Record the reading of a normal tooth first. If the affected tooth responds at a lower reading, this indicates hyperemia or pulpitis. If the affected tooth responds at a higher reading, this indicates pulp degeneration. Disadvantages of electric pulp tester: Child may become apprehensive and gives false response. Gives false positive response when content of pulp is liquid (liquifaction necrosis).

5-Physical condition of patient:

Seriously ill children e.g. heart disease, nephritis, leukemia or tumors should not be subjected to the possibility of an acute infection resulting from pulp therapy. Moreover, the pulp might not posses normal regenerative power. Extraction of the involved tooth after proper premedication with antibiotics is the treatment of choice in such conditions.

Vital Pulp Therapy

Pulp Capping The aim of pulp capping is to maintain pulp vitality by placing a suitable dressing either directly on the exposed pulp (direct pulp capping) or on a thin residual layer of soft dentine at the base of the cavity (indirect pulp capping).

Indirect Pulp Capping

Definition: It is the procedure in which only the gross caries is removed from the lesion, while the remaining carious dentine which if removed would result in pulp exposure is covered with a material which promotes healing. Indication: Teeth with deep carious lesions approximating the pulp, free of any clinical or radiographic signs of pulp disease.

Technique:
First visit: Administer local anesthesia and isolate tooth with rubber dam. Preoperative appearance of a deep lesion close to pulp in an asymptomatic vital tooth. Gross caries is excavated, while soft dentine in the deepest portion is left and covered with calcium hydroxide paste and a temporary dressing. Tooth should not be re-entered for 6-8 weeks. During that time the soft caries becomes harder and calcium hydroxide will stimulate the formation of secondary dentine and the remaining microorganisms will be destroyed by bactericidal action of calcium hydroxide.

Second visit: The tooth is reopened and remaining caries is carefully removed. Sound dentine is apparent which protects the pulp. Apply calcium hydroxide dressing and restore the tooth. If a small exposure is encountered a different type of treatment is provided.

Direct Pulp Capping

Definition: It is the procedure of covering the exposed ital pulp with a material which promotes healing. Indications: Small pinpoint exposure surrounded by sound dentine, produced accidentally during cavity preparation or due to trauma. Absence of pain with the exception of pain during eating. Normal vital pulp. No bleeding at exposure site or an amount that would be considered normal. Normal radiographic findings.

Technique:

Administer local anesthesia and isolate tooth with rubber dam. When pulp is exposed during the last stages of caries removal, carious dentine chips will be pushed into the pulp tissue which becomes contaminated resulting in pulpitis. So enlarging the exposure site is needed to wash away carious fragments and allow direct contact of capping material with pulp tissues. Flush the cavity with noraml saline and dry the area. Cap the pulp with calcium hydroxide followed by zinc oxide eugenol then zinc phosphate cement and the permanent restoration. N.B. Direct pulp capping is not encouraging in primary teeth because pulp tissue ages early and less active undifferentiated mesenchymal cells are available. Also, during Process of root resorption, cells may transform to odontoclasts causing internal resorption.

Pulpotomy
Definition: It is the removal of coronal pulp tissue till the level of enterance of pulp canals and capping the radicular pulp tissue to keep it in a good condition. Indications: In primary and young permanent teeth with wide pulp exposures when the tissues adjacent to exposure site show slight evidence of inflammation. Slight amount of bleeding at exposure site which is considered within normal. Normal clinical and radiographic signs.

Types: According to the capping material used: -Calcium hydroxide pulpotomy. -Formocresol pulpotomy.
Formocresol pulpotomy: There are two methods: -One visit technique. -Two visits technique

 Administer local

One visit formocresol pulpotomy:

anesthesia and isolate tooth with rubber dam. Establish cavity outline and remove all caries before the pulp is exposed to prevent bacterial contamination. Remove the roof of pulp chamber using a fissure bur.

 Amputate coronal

pulp tissue till enterance of root canals with sharp spoon excavator or large round bur at low speed.

 Control bleeding with

cotton pellet moistened with water placed over amputated pulp stumps for 3 minutes. When bleeding is arrested, apply a cotton pellet moistened with formocresol for 3-5 minutes. Pulp stumps appear dark brown (fixed by formocresol).

 Cover radicular pulp

stumps with zinc oxide eugenol paste, fill pulp chamber with temporary cement and prepare the tooth for chrome steel crown. N.B. Success rates up to 98% have been reported using pulpotomy technique in vital primary teeth.

Preoperative

Postoperative

Two visits formocresol pulpotomy:

If there is any sign of hyperemia following
amputation of coronal pulp (pain or excessive hemorrhage) indicating that inflammation is present in the tissues beyond the coronal portion of the pulp , two visits formocresol pulpotomy , partial pulpotomy or even extraction of the tooth is indicated. 1-After pulp amputation, a cotton pellet moistened with formocresol is placed over amputated pulp stumps and covered with temporary dressing. 2-In the second visit after 2-3 days isolate tooth with rubber dam without local anesthesia, remove the dressing and pellet and complete the procedure as one visit technique.

Calcium hydroxide pulpotomy:

It is indicated in young permanent teeth with

exposed vital pulp and incomplete root formation. After pulpotomy and formation of healthy clot , a layer of calcium hydroxide is applied followed by zinc phosphate cement then the permanent restoration. Under calcium hydroxide, the pulp vitality is maintained; it organizes an odontoblastic layer to lay down reparative dentine and gives the chance for the root to complete its development. This procedure gives 61% success.

Pulpectomy
Partial pulpectomy: Definition: It is the removal of coronal pulp tissue and as much as possible of the contents of root canals without interfering deeply into the apical portion. Indications: It is indicated in primary molars (due to difficulty of performing complete pulpectomy because of difficulty to obtain adequate access to root canals in the small mouth of children and due to the morphology of root canals such as lateral brancings and ramifications and presence of accessory root canals in primary molars where removal of all radicular pulp content is impossible). When the coronal pulp tissue and the tissue entering the root canals are vital but show clinical evidence of hyperemia . The tooth may or may not have a history of pain. Normal radiographic findings.

Technique:

Administer local anaesthesia and isolate tooth

with rubber dam. Remove all caries and roof of pulp chamber and amputate coronal pulp tissue. Remove all accessible radicular pulp tissue with hedstrom files or barbed broaches. File the canals to the resistance point. Usually the file stops at curvature in apical 1/3 of root.

 Irrigate canals with normal saline and dry with

paper points. Apply cotton pellet with formocresol for 3 minutes to fix remaining pulp tissue. Coat the walls of canals with creamy zinc oxide eugenol paste using the last file or paper points. Fill canals with stiffer mix of zinc oxide eugenol [ rolled into a point and condensed with root canal plugger ]. Fill pulp chamber with temporary cement and prepare tooth for chrome steel crown.

Non-vital pulp therapy

Complete pulpectomy [endodontic treatment ] Definition: It is the complete removal of coronal and radicular pulp tissue. Indications: In non-vital primary anterior teeth where the root canals are accessible. The canals may be cleaned and filled with a resorbable material such as zinc oxide eugenol , oxypara or calcium hydroxide paste

Treatment of non-vital primary molars :

Ideally a non-vital tooth should be treated by pulpectomy and root canal filling. However, pulpectomy in primary molars is extremely difficult and often not practical. A non-vital pulpotomy method is advocated.

Technique of non-vital pulpotomy:

First visit : Necrotic coronal pulp tissue is removed . Light instrumentation of canals to establish drainage. Seal a cotton pellet with formocresol or beech wood cresote or camphorated monochlorophenol into the pulp chamber for 7-10 days. The strong antiseptic action of these materials combats infection in radicular pulp.

Second visit:
Remove cotton pellet and place antiseptic
paste [ eugenol, formocresol and zinc oxide powder ] . Press antiseptic paste into root canals with a cotton pellet. Pressure forces the paste down the root canals . Restore the tooth in usual manner. N.B: This technique could be used in the presnce of sinus , abcess or some degree of tooth mobility. A sinus is expected to disappear following control of infection and a mobile tooth becomes firm as periapical bone reforms .

Commonly used capping materials:

Formocresol: Buckleys formocresol which is composed of 19% formalin , 35% cresol and 15% glycerin and distilled water . The reaction of formocresol is progressive fixation of pulp tissue with ultimate fibrosis of the entire pulp. Calcium hydroxide: Highly alkaline with pH 12 . One month after capping the pulp with calcium hydroxide , a calcified bridge is formed and the pulp underneath this bridge remains vital thus allowing continued apical development in immature permanent teeth. N.B. Electrosurgery and laser have been used recently in pulpotomy procedure.

Failures following vital pulp therapy:

1-Internal resorption: Occurs within pulp canals several months following pulpotomy. It is a destructive process due to osteoclastic activity. Pulp canals become widened, walls become thin and perforation may occur.

Etiology: All capping materials are irritating and produce some inflammtion , inflammatory cells attract osteoclasts which initiate internal resorption. Because the roots of primary are undergoing normal physiological resorption there is osteoclastic activity in the area which predisposes the tooth to internal resorption.

2-Alveolar abcess:
Develops several months following pulp
therapy. Infection may be present in bone around root apex or more commonly in bifurcation area. May be associated with fistula in chronic conditions.

Pulp therapy for young permanent teeth Apexogenesis [ vital pulpotomy ]: Indications: Vital permanent teeth with immature root development having large carious or traumatic exposures. Aim: Maintain the radicular pulp vital to allow complete root development. Calcium hydroxide placed over radicular pulp stumps stimulates the formation of a calcific bridge and successful root closure.

Apexification [ root end closure in non-vital teeth ]:

Indications: In young permanent teeth with pulp necrosis and incompletely formed apices. Aim: To promote root elongation and or calcific root closure . Even though the pulp is necrotic , epithelial root sheath of Hertwig persists and allows regeneration. Technique: The entire pulp s removed and calcium hydroxide is used to fill the root canals and is replaced every 3-4 months until apical closure occurs . The tooth is then treated with root canal therapy.

Early Childhood Caries

Definition: A specific pattern of caries affecting the primary teeth of an
infant during the first three years of age. Etiology: Wrong nursing habits (either breast or bottle feeding during night or at bedtime). Regular use of a sweetened comforter (a bottle containing sweet beverages at night, at bed time or during the day). Breast feeding beyond the normal age for weaning. Falling asleep with pacifier covered with honey or jam. Regular use of syrups for therapeutic reasons in chronic illness.

 Mechanism: When the child falls asleep, the milk or

sweetened liquid is pooled around the maxillary anterior teeth.Acidogenic bacteria produce acids. Salivary flow is decreased during sleep, so the clearance of the liquid from the oral cavity is slowed.

Clinical picture:
Clinical picture: 1-Teeth affected:

The four maxillary incisors are most affected. The four mandibular incisors usually remain

sound because the tongue lies over the lower teeth during sucking. The other primary teeth may show caries depending on how long the carious process remains active.

2-Clinical pattern:
The maxillary incisors develop a band of
dull white demineralization along the gum line that goes undetected by parents. Then the white lesions develop into cavities that circle the necks of teeth with a brown or black collar. In advanced cases the crowns of the four maxillary incisors may be destroyed completely leaving decayed brownish black root stumps.

Management
A-Prevention: National educational programs for mothers to influence their dietary habits as well as those of their infants. Water fluoridation. Early dental examination at or before the age of one year. Parents counseling: From birth, the infant should be held while feeding. The child who falls asleep while nursing should be burped and then placed in bed. The mother should wean the child as soon as he can drink from a cup at approximately 12-15 months of age. Avoid prolonged and frequent infant feeding habits. Professional application of topical fluoride. Development of appropriate dietary and oral hygiene habits at home.

B-Treatment: Cessation of habit. Sealing all caries free pits and fissures. Fluoride application. Gross excavation of carious lesions and filling cavities with re-enforced zinc oxide eugenol or glass ionomer cement to arrest caries and prevent its progression to the pulp. Pulp therapy and restoration of teeth.