Paediatric Dentistry IV
Endodontics in primary dentition
I. II. III. IV.
Developmental stages of root
Stages of root development
normally – 7 stages, for our purposes only 4 are of significance– crown is out of the
bone and is present in the oral cavity (the remaininr 3 are intraosseal)
 The first stage of development – the root is shorter than the
crown, maximally of the same length (1:1). Dentine layer s very
thinn, dental pulp cavity is large, dentinal wall are divergent apically
and the foramen apicale is very large (open apex) – shape
mesenchymal papilla
 The second stage of development – the root is longer than the
crown, dental pulp is large, dentinal walls of the root are divergent
apically, foramen apicale is large (open), dentine layer is very thinn
 The third stage of development – the root reched almost its
expected length, dentine is thicker than in previous stages, dentinal
walls are parallel in the apical part, dentine layer is thinn,
 The fourth stage of development – the root has reached the
expected length (2:1), foramen apicale is closed (physioloical
constriction), dentine is thicker, but the dental pulp cavity remaines
large.
Resorption of root
 The fourth stage of development persists for a certain time and it is
called the rest stage
 Beginning of resorption – in frontal teeth the resorption starts orally
and apically, in molars from the interradicular space and apically
 Advanced resorption – substantional part of the root was resorbed –
cave- in molars mainly from the interradicular space, so that the
roots may seemingly be long, but the resorption may expose the
dental pulp cavity – danger of irritatioon of periodontium and damage
of tooth bud of the permanent tooth on endodontic treatment
 Resorption reached the area of foramen circulare – tooth is before
elimination
Dental pulp diseases in primary
dentition
hyperemia
acute pulpitis chronic
partial total open closed
ulcerous
polypous
necrosis
gangrene
apical
periodontitis
ostitis
periostitis
phlegmone abscess
dif. diagnosis difficult
Hyperemia
reversible state
Pain – short duration
Evoked by stimuli (cold, warm, sweet,
on biting)
objectively
caries pulpae proxima
recent filling
physiologic resorption
Hyperemia
Therapy
removal of inficated masses
indirect capping - permanent filling
or
intermitent excavation - temporary filling
4 - 8 weels - permanent filling
Pulpitis
Pulpitis
Acute pulpitis
– spontaneous pain
– intervals without pain
– tooth - not able to localize
– pain - radiating (ear, eye, head)
– pulsating character
– neuralgiformic character
Pulpitis
serous pulpitis
– cold increases the pain (in case the pain is
present)
– warm milders the pain
suppurative pulpitis
– warm increases the pain (in case the pain is
present)
– cold milders the pain
Pulpitis
Symptoms last longer than 24 h ------ pulpitis totalis
pain intensity
– different, individual
– in children usually rapid course
– sometimes symptomless
– sometimes sensitivity to percussion ( sign of spreading beyond
for. apicale – beginning of periodontitis)
– partial pulpitis – pain of lower intensity, no sensitivity to
percussion
objectively
– caries pulpae proxima
– filling lacking a base
– crown fracture
– root resorption – communication with the oral cavity
Pulpitis
Differential diagnosis
– acute exacerbation of chronic pulpitis
– periodontitis (sensitivity to percussion)
– papilitis (neighbouring tooth sensitive to
percussion, pain on biting)
– incipient
• otitis media
• tonsilitis
• varicela
• aphta
• herpetic gingivostomatitis
• gingivitis/stomatitis accompanying inf. diseases
Pulpitis
therapy
necessity
to remove the diseased tissue
to treat the mesenchymal wound
to fill the root canal
Treatment of the dental pulp
Methods
pulpotomy partial
pulpotomy
pulp exstirpation
vital mortal
vital
vital mortal
Pulpitis
Coronal pulpotomy (amputation of the dental pulp)
coronal dental pulp is removed – orifices of canals
Vital pulpotomy
methods with calcium hydroxide ( MTA or Biodentine may be used instead of C-H)
– incompletely formed apex
– molars – anatomically unfavourable root canals
– advanced root resorption
Procedure:
– Anesthesia, absolute dry field isolation
– sterile instruments
– removal of carious dentine
– trepanation of the tooth (access opening)
– removal of the coronal dental pulp (round bur, excavator)
– bleeding stop
– calcium hyxdoxide application
– ZnO eugenol, ZnO phosphate cement
– permanent filling( crown)
complication: internal resorption (51 - 69%)
Partial pulpotomy
pulp horn removed only (part of the removed pulp - app. 1 mm)
The same procedure
indication:
– crown fracture
– dental pulp exposure in carious dentine
Pulpitis
1. trepanation,removal of the
dental pulp
ceiling
2. removal of the coronal
dental pulp
3. calcium hydroxide on the
canal orificia
4. calcium hydroxide on
bifurcation, zinkoxideugenol,
hermetic filling
Pulpotomy using calcium hydroxide
Pulpitis
Formocresol technique
– no dentine barrier formation
– zone of fixation ( of various thickness, resistent to autolysis,
no bacteria)
– zone of vital reactions (vital tissue, slight inflammation,
cell proliferation)
– no internal resorption reported
Composition
Sol. formald.conc. 19,0
Tricresoli 35,0
Glyceroli 15,0
Aq.dest ad 100,0
m.f.sol.
This stock solution is diluted 1:5
Pulpitis
Formocresol technique
Working procedure
zone of fixation
zone of coagulation
vital tissue
Pulpitis
Formocresol technique
Working procedure
– local anaesthesia (block),absolute dry field isolation
– carious dentine removal
– access opening (trepanation)
– dental pulp removal
– bleeding stop
– coton pelet soaked in formocresol for 5 minutes on the
pulp
– drying
– zinkoxideugenol paste application
– cement
– permanent filling (crown)
Pulpitis
Calcium hydroxide alternative
Principle of amputation wound treatment – bleeding arrest
– Ferric sulphate Fe2 (SO4)3 — 15,5% solution
( used also for gingiva retraction before impression)
– chemical reaction with blood - agglutination of ferric and
sulphate ions with blood proteins
formation of a mechanical barrier at the end of cut blood vessels
– application 10-15 seconds (cotton wool pledget)
– Rinsing (water, saline – sterile)
– Drying, application of Ca (OH)2, zinkoxideugenol cement,
phosphate cement, permanent filling
– Root dental pulp remains vital
Possibilities of the dental pulp
treatment - survey
1. Indirect capping
2. Intermitent excavation
3. Direct capping
4. partial pulpotomy
5. pulpotomy
Mortal pulpotomy
Primary molars
– Rest stadium with unfavourable anatomical conditions
– Root resorption
Working procedure
– devitalization: paraformaldehyd paste
– application directly on the dental pulp + temporary filling
– after 5-7 days coronal dental pulp removal
– Root canal orificia – covered with a paste containing
paraformaldehyd or
– Some of amputation pastes - Walkhoff, iodoform,
– cement + filling (crown)
Root filling
Root filling materials for primary dentition
requirements
– Resorption of the material – resorption of the root
– Inert to periodontium
– Inert to buds of permanent teeth
– Antiseptic properties
– Easy to applicate to the canals
– No shrinkage on setting
– Easy to remove when necessary
– Adherence to the walls
– X-ray opacity
– No discoloration of tooth structure
No ideal material at the present time
Materials used
– ZnO –eugenol cements
– Calcium hydroxide – only temporary filling
– Iodophorm based materials
1. Zinkoxid-eugenol
– Most frequently used
– Application by spiral filler
– Pressed in by a cotton pellet
– Frequently –not sufficiently filled
– Advantage – syringe application
– Overfilling – foreign body reaction in periapical tissues
– Resorption – slower than the root
2. Calcium hydroxide
– Alone - rarely
– Mixture – calcium hydroxide + iodophorm (Vitapex),
paste in syringe
– resorption – more slowly than the root
Almost ideal root canal filling material
3. Iodophorm
– Walkhoff 1928
– Jodoform, ZnO, thymol, phenol,(chlorphenol), tricresol,
tricresol-formalin
– KRI pasta (Pharchemie): iodophorme 80,8%, camphora
4,9%, alpha-chlorphenol 2%
– Different pastes: ioodophorm, parachlorphenol,
camphora, menthol, ZnO, thymol, lanoline
Gutta-percha ???
– non resorbable
– Until now – no usage in primary dentition
– Absolutely inert, no harm to tissues and tooth buds
Exstirpation of the dental pulp
Vital
– Single rooted teeth
– foramen apicale closed (rest stadium)
– Slight resorption only
Greatest importance - canines (long rest period)
The same procedure as in vital pulpotomy
– Dental pulp removed totally by barbed broach
Root filling - resorbable
– Walkhoff paste
– iodophorm paste
– zinkoxideugenol cement
– calcium hydroxide
– Vitapex (iodophorm+ calcium hydroxide )
Never the filling material for permanent teeth
Procedure: access opening, exstirpation of the dental pulp, root
canal shaping and cleasing
root filling
cement base
glassionomer cement, composite resin,
compomer material, crown
Endodontic therapy – root filling (pulp exstirpation)
Exstirpation in molars – only in the rest stage, resorption is
individual, always necessary to asses the dental age on X-ray
Resorption can be expected in:
– primary molars about 6 years of age
– primary incisors about 5 years of age
later - pulpotomy
irritation of periodontium and both mechanically
bud of permanent teeth and chemically
Resorption of primary teeth
 In the following pictures you can observe the
resorption of primary molars roots reaching into the
dental pulp cavity
Exstirpation of the dental pulp
mortal exstirpation
– removal of decayed dentine
– paraformaldehyde paste 5-7 days
– removal of the dental pulp - barbed broache
- root instrument
– root canal filling (resorbable)
Generally valid:
primary molars:
– exstirpation cannot be performed to the foramen physiologicum
– unfavourable anatomical conditions – long, narrow and curved canals
with many ramifications
For these reasons – the term may be rather deep amputation
(pulpotomy) than exstirpation
sequale of non treated pulpitis
necrose + infection = gangrene
clinical symptoms
– poor, no complains
gangrene
– disagreable odeur if the tooth
is open
– tooth is closed – diagnosis
difficult
suspicious teeth
– deep caries,dark discoloration
– loss of opacity
– no sensitivity to percussion
– no sensitivity to warm stimuli
– no response to cold
– no pain on preparation
therapy 4 possibilities
– root canal filling
– tooth is left open
– permanent drainage
– extraction
Decisive factors
– state of the root resorption
– anatomy of root canals
– cooperation of the child
– health state of the child
Necrose and a gangrene of the dental pulp in primary teeth
Root canal filling
under favourable anatomical conditions
mostly in single rooted teeth
– root canals can be endodontically treated
– rest period
– no resorption or incipient
one appointment
method
more appointments
root canal filling
– iodophorm paste
– Vitapex
– zincoxideugenol
– Gysi triopaste
1. appointment
– necrotic (gangrenous) content removal
– root canal shaping (gently)
– irrigation with antimicrobial substance (NaOCl,
chlorhexidin)
– disinfectant dressing (calcium hydroxide)
– hermetic filling
2. appointment
– root canal rinsing,drying
– root canal filling (resorbable paste)
– permanent filling ( possibly temporary filling,
permanent filling in the 3. visit)
sequale of non treated pulpitis
necrose + infection = gangrene
clinical symptoms
– poor, no complains
gangrene
– disagreable odeur if the tooth
is open
– tooth is closed – diagnosis
difficult
suspicious teeth
– deep caries,dark discoloration
– loss of opacity
– no sensitivity to percussion
– no sensitivity to warm stimuli
– no response to cold
– no pain on preparation
therapy 4 possibilities
– root canal filling
– tooth is left open
– permanent drainage
– extraction
Decisive factors
– state of the root
– anatomy of root canals
– cooperation of the child
– health state of the child
Necrose and a gangrene of the dental pulp in primary teeth
Tooth is left open: exceptionally
– tooth crown is not destroyed
– points of contact mentained (mesiodistal
dimension)
– good health state
– single tooth with gangrene
Carious dentine removed
gangrenous contents removed (from the
crown)
tooth impregnation (silver nitrate)
Permanent drainage
Modification of the previous therapy
the same indications
Possibility of tooth reconstruction
– gangrenous content removed
– root canals disinfected
– Calcium hydroxide on the cavity floor
– layer of phosphate cement
– amalgam filling
– large communication from the vestibular
surface – into the dental pulp cavity –
along the gingival margin
– calcium hydroxide rinsed out
– cavity can be cleansed
Advantage (against the previous method)
– improved oral hygiene
– improved masticatory function
– improved function as space- maintainer
Permanent drainage
Tooth is left open: exceptionally
– tooth crown is not destroyed
– points of contact mentained (mesiodistal
dimension)
– good health state
– single tooth with gangrene
Carious dentine removed
gangrenous contents removed (from the
crown)
Root canal irrigation (chlorhexidine)
tooth impregnation (fluorid)
Permanent drainage
Modification of the previous therapy
the same indications
Possibility of tooth reconstruction
– gangrenous content removed
– root canals disinfected
– Calcium hydroxide on the cavity floor
– layer of phosphate cement
– permanent filling
– large communication from the vestibular
surface – into the dental pulp cavity –
along the gingival margin
– calcium hydroxide rinsed out
– cavity can be cleansed
Advantage (against the previous method)
– improved oral hygiene
– improved masticatory function
– improved function as space- maintainer
Contraindications of endodontic
treatment in primary dentition
– teeth which cannot be restored
– uncooperative patient
– systemic disease
– orthodontic reasons for extraction
Pulpitis acuta partialis
frontal and distal teeth
stadium
– incomplete root development -very rarely – because of age of the child
– rest period
– resorption
Coronal pulpotomy
incomplete root development vital - very rarely
rest period vital
molars also mortal
resorption vital
molars also mortal
Pulpitis acuta totalis
-frontal teeth
incomplete root development
extraction
rest stadium
dental pulp exstirpation
-root resorption
-extraction
molars
exstirpation cannot be in reality
performed, rather deep
pulpotomy, considering that
anatomic conditions are
unfavourable
therapy - molars
– incomplete root
development
extraction
– rest stadium
vital exstirpation (deep pulpotomy)
Root canal filling
root resorption
a. tooth after mortal
devitalization is left open,
remaining root dental pulp is
mummified
b. mortal devitalization, orificia
covered by iodophorm or
Walkhoff paste (or others),
filling or crown
c. tooth extraction
Pulpitis chronica aperta
b. polypous pulpitis
– treatment is not necessary (no complains)
– vital pulpotomy
– extraction
Necrose, gangrene
1. root filling - rest period, favourable conditions
2. permanent drainage
3. tooth is left open
4. extraction
Favourable conditions
1. cooperative child
2. good health state
3. good state of dentition
4. favourable anatomical conditions of root canals
5. root development completed
6. no or incipient root resorption
Apical periodontitis in primary dentition
Infection crossed the foramen apicale
process: acute chronic acute exacerbation
(recrudescence)
acute apical periodontitis
– intensive pain, no rest intervals
– pacient is able to identify the causative tooth
– sensitive on biting, percussion, touch
– not possible to calm with analgetics
– slightly movable
– tooth is slightly elevated from the socket
– mild gingivitis
Apical periodontitis in primary dentition
Bone in children - enables easy penetration of infiltration
redness in apical region in vestibulum
incipient periostitis (periosteal inflammation)
Therapy - tooth trepanation
extraction
single rooted teeth (no resorption)
root canal treatment only
molars rarely
Extraction - immediately –if easy extraction is expected
in other cases trepanation + ATB
extraction postponed
Chronic apical periodontitis
no complains
– X-ray –enlargement of the periodontal space, radiolucency
– radiolucency of the adjacent bone = ostitis
– in primary dentition no granuloma
ostitis: extraction – danger for buds of permanent teeth
More frequent in primary dentition
Inflammation into spongious bone
penetrates rapidly = incipient
stage
Pain: increasing, pressure inside
mild swelling
Finding : non vital tooth
– expressed sensitivity to
percussion, touch
– mobility of the tooth
– swelling of tissues
– infiltration sensitive - pain
– lymph nodes enlarged,
swollen, sensitive
– alteration of the patient´s state
longer duration
– increasing pain
– spreading of the swelling
– fluctuation of infiltration
perforation of periosteum
– submucous abscess (relief)
• into oral cavity-fistel
• chronic periostitis
– perimaxillary inflammation
– perimandibular inflammation
course
– no problems
– extraoral fistel
– serious sepsis
danger
– spreading into fascial spaces
Cave – trigonum mortis!!!
Periostitis in primary dentition
therapy
– basic intervention = to enable escape of exsudation
– tooth trepanation
– incision
– extraction
causative tooth must always be extracted
tooth crown present, easy extraction expected
immediately+ ATB cover
other cases
– trepanation, incision, ATB
– postponed extraction – acute symptoms have subsided
submucous abscess
– immediate extraction,no incision necessary