Pediatric endodontics

BONART  ART-E1Maximum power output: 50WPower supply: 110V±5% 50/60Hz 92VAWork frequency: 1.5~1.7MHz±5%Electrode tip set of 7

T1-DiamondT2-Small LoopT3-Large LoopT4-Fine WireT5-Heavy WireT7-Oval LoopT9-Heavy Ball

PEDIATRIC ENDODONTICS

Dr Nikhil Srivastava       MDS, FICD, FDS-RCPS(Glasg)Prof & Head, Paedodontics & Preventive DentistryPrincipal, Subharti dental College & HospitalDean, Faculty of Dental SciencesSwami Vivekanand Subharti UniversityNH-58, Delhi-Haridwar-Meerut Bypass RoadMeerut 250005 (UP) India

Sunny goldLaser source: GaAlAsOutput power :500mWWavelength: 808nMTimed :0-99mDimension (mm) :350×250×130Weight :3KgElectrical input :AC220Vor110V

endo + dontics “Study of the inside of the tooth” Definition- branch of dentistry concerned with

the prevention, diagnosis & Tt of the diseases or injuries to the pulp.

ULTIMATE GOAL OF DENTISTRY….Total prevention of caries.Despite of emphasis on preventive dentistry,premature loss of primary & young permanent

teeth continues to be common.

3

OBJECTIVE OF PULP THERAPY….. Conservation of tooth in healthy state,

functioning as an integral part of dentition.WHY CONSERVE PRIMARY TEETH ???1. Mastication2. Speech- loss of anteriors before 3 yrs- altered sppech.3. Esthetics4. Contribute to growth & development5. Best space maintainers6. Prevention of abnormal oral habits.7. Psychological effect associated with tooth loss

4

DIFFERENCES B/W PRIMARY & PERMANENT TEETHA) morphological…..1. Smaller in all dimensions2. More MD width than CI (cup shaped ant. & squat shaped post)

3. Narrow & long roots compared to crowns (more R/C ratio)

4. Prominent labial & lingual cervical III (cervical bulge)5. Neck convergence.6. Facial & lingual convergence (narrow occlusal table)7. Thin E.8. Thin D.

5

9. Large pulp chambers 10. High pulp horns (MB horns) 11. Flared & curved roots.

B) histological….1. E. rods at cervical III r horizontal/ occlusally placed.2. Less inorganic content 3. DEJ smooth4. CEJ scalloped5. More cellular content in pulp6. More accessory canals at furcation.7. Tortuous/ ribbon shaped pulp space

6

8. Develops from only one lob (no mamellons)

9. Neural components r last to mature & first to degenerate ie why no senstivity.

DIAGNOSIS OF PULPALLY INVOLVED TOOTH….1. Clinical examination- with explorer; see the exposure

2. Radiographic examination- a. exposure- radioleucency reaching plup space. b. PA pathosis- broadening of PDL space c. calcification (advanced pulpal degeneration) d. root resorption. e. lamina dura- discontinuity.

7

3. Pulp tests- Unreliable electric & thermal tests only tell about vitality. 4. Pulp exposure & hemorrhage- excessive

hemorrhage at the exposure site – an indication of extensive inflammation; candidate of RCT

5. Blood flow- laser dopler flowmetry pulse oxymetry

8

PULP PROTECTIVE PROCEDURES… (Vital Pulp Therapy)1. Indirect pulp therapy (IPT)2. Pulp capping3. Pulp curettage (partial pulpotomy)4. Pulpotomy5. Partial pulpectomy

1.Indirect Pulp Therapy- ‘tech of avoiding pulp exposure in deeply carious teeth

in which there exists no clinical evidence of pulpal degeneration/ PA pathosis’

9

RATIONALE…. zone of affected D exists b/w pulp & the zone of

infected D and when this infected D is excavated , the affected D can remineralise and odontoblasts form reparative D, thus avoiding pulpal exposure.

TECHNIQUE1. Anaesthesia if required2. Isolation3. Excavation of superficial soft caries with spoon excavator/

bur4. Sedative dressing of ZnOE/ CH for 6-8weeks5. Perm. restoration

10

Note- a. ZnOE serves same purpose as CH ie reparative D formation

b. rate of D deposition- 1.4 micro m/ day c. greater D deposition is seen in primary

than perm teeth.2. Pulp CappingOld terminology- indirect & direct pulp capping/

therapy…Pulp capping means direct pulp capping/ therapy.‘the procedure involves application of medicament

directly on to the exposed pulp in an attempt to preserve its vitality’

11

INDICATIONS.. 1. mechanical pulp exposure

- during cavity preparation - forceful excavation of caries 2. recent # with pulp exposure 3. small carious exposure ( less than 0.5mm) without

H/O spontaneous pain.CONTRA INDICATIONS.. 1. frank carious exposure 2. exposure with H/O spontaneous pain 3. excessive haemorrhage at exposure site. 4. no haemorrhage 5. exposure with purulent discharge.

12

6. radiographic evidence of PA pathology/ resorption/ calcification.

NOTE: not indicated in primary teeth, rather pulpotomy should be attempted.

CAPPING AGENTS-a.CHb. Strontium hydroxidec. HAd. tri- and octa Ca phosp.e. Calcitoninf. Ca eugenol cementg. MTAh. Biodentine

13

commercial preparations— a. CH powder b. pulpdent c. Nucap d. Life e. DycalMechanism of action…. CH in contact with pulp necrosis of adjacent pulp layer

below necrosed zone.. Zone of inflammation

14

increased blood supply inflow of WBCs

Ca from blood gets deposited in the inflammed zone.NOTE: bridge formation is better seen with CH

powder & pulpdent…..necrosed layer resorbs first.

PROGNOSIS-Is good when……a. Carried out in isolation & aseptic conditions.b. Small exposure sitec. Little or no damage to pulpd. Not to push dentinal chips in to the pulpe. Done in young perm. teeth

15

NOTE: mechanical exposure has better prognosis than carious exposure.

3. Pulp Curettage (pulp curettage)not in practice, pulpotomy is preferred.Technique..AnaesthesiaEnlarge the exposure site with round burStop bleedingRestore with CH lining & ZnOE.

4. Pulpotomy“ surgical removal of the coronal pulp with the objective

of preserving the vitality of radicular pulp & to relieve pain in Pts with acute pulpalgia”

16

Rationale- when coronal pulp gets exposed due to trauma, during operative procedure or during excavation of caries, entry of bacteria in to the pulp produces various inflammatory response & localised infection.

Through surgical excision, inflammed & infected pulp is removed, leaving behind uninfected & vital pulp in RC. Then a dressing of material is placed over the amputated pulp stumps to protect underlying tissue & to promote its healing.

Indications1. vital pulp exposure, mechanical or traumatic in which

inflammation is considered to be confined to coronal pulp only.

17

2. carious exposure (1-2mm) without H/O spontaneous pain.

3. Young permanent tooth with vital pulp exposure & open apex.

selection criteria…..a. Restorable toothb. Atleast 2/3rd root remainingc. No radiographic evidence of root resorption & bone

loss. d. No fistulae. Easily controllable bleeding.

18

Contra indications- all indications of pulpectomy or extraction.

1.A non-restorable tooth2. Tooth nearing exfoliation3. H/O spontaneous toothache 4. PA/ furcal pathosis 5. pulp that doesn’t bleed6. Excessive hemorrhage7. serous/ purulent discharge8. Presence of fistulaClassification-1. Devitalization (mummification/ cauterization)-Destroys vital tissues

19

Agents – formocresol, Laser, elecrosurgery

2. Preservation (minimal devitalization/ non-inductive)

-preserve maximum vital tissues- No reparative D formation Agents- Gluteraldehyde

Ferric Sulphate ZnOE

20

3. Regeneration- (inductive/ reparative)-Formation of D

Agents- CH MTA BMP Enriched collagen freezed dried bone.

Mortal Pulpotomy- done in compromised cases

agents- formocresol beechwood cresol

21

Technique- 1. anaesthesia…. Rule of 10 (age+ tooth no.)

2. isolation3. Access & pulp extirpation - high speed with coolant - roof removed - excavate pulp4. Irrigation & control of hemorrhage- 3-5min pressure

22

5. Application of medicament I. formocresol.. 5min in soaked cotton ii. Electrosurgery..tip kept close to pulp tissue for 1-2

sec.( repeat 2-3 times until brown colour of tissue appears ) iii. Laser…diode laser of 980nm with 0.5mm tip for

2.3min. Iv. Gluteraldehyde.. 2min in soaked cotton v. ferric

sulphate…15.5% soaked in cotton, kept for 15sec. vi. CH- only 1/3rd of the total in amalgam carrier to b

placed.6. Fill the chamber with ZnOE.7. SSC

23

Histology of formocresol pulpotomy…………… 7-14 days later, 3 zones seen microscopically zone 1: fixation (broad acidophilic), zone 2: atrophy with less fibres & cells and zone 3: inflammatory cells which diffuses into normal

pulp.

Drawbacks- carcinogenic & mutagenic - more time for application - smaller molecules, greater diffusion.

24

Soln used.. 1/5th conc.(Buckley’s soln) Advantages of Gluteraldehyde… - less time (2min)

- larger molecules: less systemic destribution - only zone of fixation: no zones of atrophy or

inflammation.

Pulpectomy (RCT)Complete removal of coronal & radicular pulp.RCT- after pulpectomy, RC is made sterile &

filled with biocompatible material.

25

Indications--- all primary teeth with pulpal involvement that has spread beyond coronal pulp r candidates for pulpectomy, whether vital or non vital.

Contra-indications- i) non-restorable teeth ii) loss of supporting tissues iii) radiographic evidence of internal root

resorption. iv) perforation- rc/ chamber v) pathological root resorption involving more

than 1/3rd root vi) +ce of cyst (dentigerous/ follicular)

26

steps of RCT- i) access opening & pulp extirpation ii) shaping & disinfection iii) obturationi) Access-Anteriors- on the lingual surface just incisal to cingulum

EXCEPT Max incisors…. Labial- save lingual surfaces for strength.

Posteriors- NO conventional cavity large opening parallal to external surfaces.Remove pulp with round bur/ excavatorii) Shaping & disinfection- a. w/l with file in the canal, 2-3mm short of apexb. Paralleling tech for x-ray

27

c. Ni-Ti file due to flexibility d. Shape till 30-35 number e. Step back tech not followed

f. Bcoz of tortuous canals & pulpal ramifications, mecahnical preparation is not adequate. Copious irrigation with 2.6% NaOCl & H2O2 required.

(chemo mechanical preparation/ chemical shaping)iii) ObturationCanal ready for obturation ? ADSOCTAsymptomatic, Dry canal, no Sinus formation, no foul

Odour, -ve Culture, intact Temporary restn

28

Obturating material- resorbable

- biocompatible - rate of resorption similar to root

resorption.Material used….. 1. ZnOE,2. Endoflas ( ZnOE+Iodoform+CaOH),3. Vitapex(CaOH+Iodoform),4. Walkhoff paste(parachlorophenol+camphor+menthol),5. KRI paste(walkhoff paste+iodoform)Technique….a. Confirm above findingsb. Dry the canalc. Canal luted with thin mix of ZnOE/ endoflas

29

d. thick mix of ZnOE/ endoflas/ CaOH paste introduced in the canal till back fill is achieved ( either with syringe or manually)

e. pulp chamber filled with ZnOE & tooth restored with SSC.

(GP is used when perm tooth bud is absent)

Apexification

30

Apexification ‘method of inducing apical closure by the

formation of osteocementum or similar hard tissues or continued apical development of the root of an incompletely formed tooth with non-vital pulp’

Apexogenesis – “physiological development of the root end & its formation”

31

Rationale…when the pulp of an immature tooth becomes dead either due to trauma/ caries, its hertwig’s epithelial sheath stops its function of root end formation .

These teeth present with blunderbuss canals in which obturation by orthograde methods is nearly impossible. By the introduction of suitable medicament, apical barrier is produced at the same time length of the root is increased & canal is then obturated using thermoplasticised tech.Blunderbuss canal- diameter of rc at cervical iii is less

than that of apex

32

Materials used for Apexification… i) CaOH alone or in combination with CMCP

(bactericidal) + BaSO4 (radio opacity, 8:1)ii) collagen+ Ca phos. Gel (results faster than CaOHiii) Tri Ca Phosp.iv) Osteogenic protein-1 results similar v) MTA as that of CaOHTechnique-Use of CaOH in apexification was first reported by

Kaiser (1968)FIRST APPOINTMENTi) Isolationii) access- st. line

33

iii) Instrumentation- W/L- 2-3mm short

- circumferential filing - 120-140no. Files(90, 100,110, 120, 130, 140 black)iv) Irrigation- NaOCl + salineSECOND APPOINTMENTv) Dry the canal- blunt end of paper pointvi) Material placement- thick paste of

CaOH+BaSO4+CMCP … with amalgam carrierOr, Syringevii) Fill till CEJvii) A layer of CaOH powderviii) Access sealed

34

periodic recall-Normal time 6-24months 3 months recall… see evidence NOTE 4 types of closure Case 1 normal closureCase 2 apical closure but canal blunderbussCase 3 no radiographic change but definite apical stopCase 4 radiographic evidence of apical plug short of

apex

35

Factors delay the apexification- 1. inter appointment symptoms 2. +ce of radiolucency 3. defective coronal seal If appear, repeat the procedure Obturation After successful apical closure……

obturate the canal with thermoplasticised GP obturating tech

36

Since such teeth have thin dentin & short roots, post & core is NOT recommended

To provide strength…. Remove GP till the junction of middle & apical III, acid etch the canal and fill with composite.( self cure composite have less working time while light cure have problem of incomplete polymerisation ) Clear plastic post is used to polymerise in the deepest layer & on cured excess is cut

37

Apical barrier technique….. apexification is for 2 yrs alternative Tt which is quick … is the use of apical

barrier tech which allows Immediate obturation.Material used… MTA (grey & white…. FeO & MgO in grey p/l ratio 3:1, mixed with water setting time 3hrs, pH 10.2 during mixing & 12.5

when set

Technique---- * canal cleaned & medicated with CH * After 1 week – irrigate with NaOCl * dry the canal, pack 3-4mm of MTA at apical III * wait for 4-6 hrs… allow to set * obturate

38

APICAL BARRIER TECHNIQUE

39

Mechanism & Histology of Apexification CH + PA tissues differentiation of adjacent

connective tissues to form calcified material in continuation with lateral wall of the root surface.

calcified tissue– osteoid (bone like) - cementoid - osteo-cementum

Note- apical plug formed is not hard ( cheesy consistency)

- porous (minute communication) - i.e. why important to obturate---------------------*----------------------*---------------------

*--------