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CONTENTS

 INTRODUCTION
PEDIATRIC ENDODONTICS  HISTOLOGIC CONSIDERATIONS
 DIAGNOSIS
 INDIRECT PULP CAPPING
AND  DIRECT PULP CAPPING
 PULPOTOMY
INSTRUMENTATION  PULPECTOMY
 APEXOGENESIS
 APEXIFICATION
Presented by:  REFERENCES
Dr Jasdeep
BDS, MDS( Pediatric
& Preventive Dentistry)

PULP MORPHOLOGY

 Pediatric endodontics deals with the management of

pulpally involved teeth in children.

 Various methods and medicaments have been

suggested depending on pulpal status. Anatomic Differences between
 “The successful treatment of pulpally involved tooth is to Primary & Permanent Teeth
retain that tooth in healthy condition so that it may fulfill
its role as a useful component of primary and young
permanent dentition” ( Lewis )

 There is no better space maintainer than retained primary

tooth

PRIMARY TEETH PERMANENT TEETH  roots flare outward from  Comparatively less flare
the cervical part to a
 Pulp chamber is larger in relation  Smaller in relation to crown greater degree
to the crown size size

 Pulpal outline follows DEJ more  Follows DEJ less closely

closely
 roots of primary anterior
 Pulp horns comparatively less  Less narrower
 Pulp horns are closer to the outer
teeth are more narrower
far from the outer surface
surface mesiodistally

 It is more cellular and vascular

 Less cellular and vascular

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 Root canals are more  Root canals are well defined  Pulp nerves pass to the  Nerves terminate among the
with less branching odontoblastic area, where they odontoblasts and even
ribbon like (Hibbard and terminate as free nerve
Ireland 1957) endings beyond the predentin

 Density of innervation is less  Density of innervation is

 Floor of the pulp chamber  Floor of the pulp chamber and neural tissue is first to
does not have any accessory degenerate when root more
is more porous rosorption occurs
canals

 Localization of infection and

 Roots have enlarged apical  Infection and inflammation
 Foramen are constricted and inflammation is poorer
foramen there’s reduced blood supply is localized

HISTOLOGIC CONSIDERATIONS
 pulp is primarily connective tissue with considerable Responses to thermal tests
healing potential.
 No response  Non-vital pulp

 distinguished from other connective tissues

 Mild to moderate pain which subsides in 1-2 sec  Normal

by presence of odontoblasts  Strong momentary pain which subsides in 1-2 sec 

absence of histamine-releasing mast cells
tissue confinement in a hard cavity with little
collateral circulation and vascular access limited to
the root apex.
Reversible pulpitis
 Moderate to strong painful response that lingers for several
seconds or longer after the stimulus has been removed 
Irreversible pulpitis.

 coronal cellularity and apical vascularity are increased in  resultant reduced blood supply in mature
primary and young permanent teeth.
 Pulps become more fibrous, less cellular and less vascular permanent teeth favours a calcific response and
with age. healing by “calcific scarring”.
 different pulp responses exist between primary and young
permanent teeth to trauma, bacterial invasion, irritation and  Primary teeth with their abundant blood supply
medication.
demonstrate a more typical inflammatory
 Anatomic differences may contribute to these responses. response ----internal and external root resorption
from calcium hydroxide pulpotomies.
 Primary roots have and enlarged apical foramen in contrast
to constricted foramen of permanent

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 permanent teeth, nerve fibers terminate mainly
among odontoblasts and even beyond predentin.
 In primary teeth, fibers pass to the odontoblastic
area where they terminate as free nerve endings.
 reparative dentin formation more extensive in
primary than in permanent teeth.
 localization of infection and inflammation is
poorer in primary pulp than permanent teeth.
 Spontaneous pain is a throbbing constant pain
keeping patient awake at night.
 indicates advanced pulpal damage
 can also be observed when interdental papilla is inflamed
owing to food impaction.
 Sensitivity to pressure indicate pulpal damage extending to
PDL causing extrusion of tooth
 be due to sealant placed in excess or high restoration
causing hyper occlusion.
CLINICAL EXAMINATION
visual and tactile examination :
 thorough examination of hard and soft tissue relies
on checking three C's i.e. Colour, contour,
consistency.
 redness and swelling of vestibule or grossly decayed
teeth with draining paruli, are definitely indicative of
pulpal pathoses.
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DIAGNOSIS
HISTORY AND CHARACTERISTICS OF PAIN
 accurate history must be obtained
 type of pain, duration, frequency, location , spread and
aggravating and relieving factors
 Provoked pain is stimulated by thermal, chemical or
mechanical irritants, and reduced or eliminated on removing
noxious stimulus indicating dentin sensitivity due to a deep
carious lesion or a faulty restoration.
 pulp is in transitional state and condition is reversible.
 Children often complain of toothaches during eruption of
first permanent molars.
 carefully ascertain whether this is due to pericoronitis or
to biting on an operculum rather than due to pulp
condition.
percussion :
 Sensitivity to percussion reveal inflammation
has progressed to PDL (acute apical
periodontitis)
 Belanger suggests --percussion should be done
very gently with tip of a finger and not with
end of a dental mirror to prevent exposing
child to unnecessary uncomfortable stimuli.
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mobility

 may be due to physiological or pathological cause.

palpation
 use two mouth mirror handles to apply alternating lateral forces in a
 done with fingertip using light pressure facial lingual direction

A measure of mobility is :-
 to examine tissue consistency and pain response.

Wyman's index (1975)

 Fluctuation felt by palpating a swollen mucobuccal fold acute
dentoalveolar abscess
0 Horizontal < 0.2 mm
 Can detect bone destruction following chronic dentoalveolar 1 Horizontal <02-1m
abscess 2 Horizontal <1-2 mm
3 Horizontal > 2 mm and vertically
 Sensitivity to palpation in the vestibule acute apical pathologic
process.

pulpal exposure and hemorrhage

 Compare mobility of suspicious tooth with its
contralateral tooth.  size of the exposure, the appearance of the pulp and the amount of
hemorrhage are important factors.

 significant difference indicates pulpal inflammation .  pinpoint exposure may have pulpal inflammation varying from
minimal to extensive to complete necrosis.

 do not misinterpret as pathologic , mobility present in  massive exposure has widespread inflammation or necrosis and is not a
primary teeth during normal time of exfoliation . candidate for any form of vital pulp therapy except in young permanent
teeth with incomplete root development.

 Excessive hemorrhage at an exposure site or during pulp amputation is

evidence of extensive inflammation. These teeth should be considered
candidates for pulpectomy or extraction.

radiographic examination  Pulpal changes, such as pulp calcifications

(denticles) and pulp obliteration.
 valuable aids in visualizing presence or absence
of the following:
 Pathologic root resorption, which may be internal
 Deep caries with possible or definite pulp or external
involvement.

 Deep restorations close to a pulp horn.

 Periapical & interradicular radiolucencies of
 Successful or failing pulpotomy or pulpectomy. bone.

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Pulp vitality tests
CONVENTIONAL METHODS
THERMAL PULP TESTING: first reported by Jack
in 1899 involving application of cold or heat to
determine sensitivity to thermal changes
1. HEAT TEST useful when chief complaint is
intense dental pain upon contact with any hot
liquid or food.
If no response occurs substance moved to central
portion of crown or closer to the tooth cervix.
When a response occurs, remove substance
immediately.
Application for hot water
isolate tooth under rubber dam , immerse in
“coffee-hot” water delivered from a syringe and
patient's reaction noted.
Responses to thermal tests
 No response  Non-vital pulp
 Mild to moderate pain which subsides in 1-2 sec  Normal
 Strong momentary pain which subsides in 1-2 sec 
Reversible pulpitis
 Moderate to strong painful response that lingers for several
seconds or longer after the stimulus has been removed 
Irreversible pulpitis.
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performed via different techniques
 area is isolated and dried
 warm air directed to exposed surface and response is noted.
 If higher temperature needed use hot water, a hot burnisher,
 hot gutta-percha, or hot compound, or any instrument that
deliver controlled temperature
 When using solid substance such heat is applied to the occluso-
buccal third of the exposed crown.
COLD TEST
applied in several ways.
 stream of cold air directed against crown
 Ethyl chloride spray
 ice
 Carbon dioxide dry-ice snow
ELECTRIC PULP TESTING
 depends on vital sensory fibres in pulp.
 does not provide information about the vascular supply which is a true
determinant of pulp vitality.
Technique
 Isolate area to be tested with cotton rolls and saliva ejectors and air-dry.
 Apply electrolyte against dried enamel.
 Retract patient's cheek or lip away from tooth electrode with free hand to
complete electric circuit.
 Introduce minimal current and increase slowly asking patient to indicate when
any “tingling or warmth” sensation occurs.
 Record results according to numeric scale.
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A false negative response can occur when:

 Higher current required  Chronic inflammation
 Calcification in pulp tissue or dentin has been
 Lower current  Acute pulpitis extensive.
 Teeth with extensive restorations and in pulp-
 No response  Non-vital tooth.
protecting base.
false positive response occur-  Recently traumatized teeth.
 Recently erupted teeth with incomplete root
 Moist gangrenous pulp is present in a root canal.
formation.
 Multi-rooted teeth in which the pulp is partially necrotic, with some nerve  Patients with an unusually high pain threshold.
fibres still vital in one or more of the root canal.
 Patient who has been premedicated with
 Electrode contact with a metal restoration or gingiva. analgesics, narcotics or alcohol

TEST CAVITY RECENT METHODS

 used only when other test methods are deemed impossible or
results are inconclusive.  pulse oximetry

 explain procedure to patient as it must be done without  dual wavelength spectrophotometry

anesthesia.
 laser doppler flowmetry
 Make a preparation through enamel or existing restoration until
dentin is reached.  transmitted –light photoplethysmography

 liquid crystal testing

 If pulp is vital, heat from bur generate a response from patient;
 it may not necessarily be an accurate indication of degree of  hughes probeye camera
pulpal inflammation.
 computerized infrared thermo graphic imaging (ti)

Indirect Pulp Capping

Indications
Depending on the pulpal status PULP THERAPY
1) History
can be:
a) Mild discomfort from chemical and
thermal stimuli
CONSERVATIVE
b) Absence of spontaneous pain

 involves preservation of pulp vitality 2) Clinical examination

 includes pulp capping and pulpotomy procedures. a) Large carious lesion
b) Absence of lymphadenopathy
c) Normal appearance of adjacent gingiva
RADICAL d) Normal color of tooth
e) No mobility
 includes pulpectomy and apexification.

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Direct Pulp Capping

Radiographic examination  “Pinpoint” mechanical exposures surrounded with sound

dentin.
a) large carious lesion in close proximity to the pulp  exposed pulp tissue be bright red in color

 slight hemorrhage easily controlled

b) normal lamina dura

 traumatic exposures in a dry, clean field which reported

c) normal periodontal ligament space within 24 hours.

d) no inter-radicular or periapical radiolucency  directpulp capping in a primary tooth is not

recommended.

Pulp Capping Agents Pulpotomy

 Calcium hydroxide

 Zinc oxide-eugenol

 Bonding agents
Amputation of the affected or infected coronal
portion of pulp, preserving the vitality and
 Biodentin function of all or part of the remaining radicular
pulp.
 Theracal

 Mineral trioxide aggregate

 Bioactive materials

Pulpotomy

Amputation of the affected or infected coronal
portion of pulp, preserving the vitality and
function of all or part of the remaining radicular
pulp.
Indications
 Primary teeth - infected coronal tissue can be amputated and
remaining radicular tissue is judged to be vital
 Permanent teeth - pulp is exposed and all infected or affected
coronal pulp tissue judged to be vital
 Time constraints or economic reasons

 Young permanent teeth with incompletely formed apices

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Pulpectomy
AGENTS

 Formocresol Objective:

 Glutaraldehyde  Maintain the tooth free of infection.

 Ferric sulfate
 Biochemically cleanse and obturate the root canals.
 Mineral trioxide aggregate (MTA)
 Promote physiologic root resorption.
 Bioactive molecules

 Electrosurgical  Hold the space for the erupting permanent tooth.

 Lasers

Endodontic Instruments

Rotary Ni-Ti files

 Exploring
 Provide consistently dense fill

 Debridement  Allow greater apical enlargement

 Prevent apical exposure

 Shaping
 Better shape

 Reduce time
 Obturation

Obturation Materials
Ideal Requirements:
 Require skill  Similar resorption rate.

 Non irritant to periapical tissues.

 Resorption in roots of primary teeth can cause problem
 Should not coagulate any organic remnants in the canal.

 Breakage of files  Adequate disinfection and sealing of canals.

 Non toxic.
 Repeated use – increase fracture risk
 Shouldn’t dissolve in oral fluids.

 Easily resorbs from periapical area

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 Proper consistency Commonly used materials are:

 No discoloration - Zinc oxide eugenol

 Radiopaque - Calcium hydroxide

 Retrievable if required
- Iodoform pastes (walkhoff paste, KRI paste ,
maisto’s paste, vitapex , endoflas)
 harmless to adjacent tooth bud.

Obturation techniques
 Mechanical syringe: Greenberg In 1971
 PAPER POINTS by Spedding (1973)
 Tuberculin Syringe: Aylord And Johnson In 1987
 ENDODONTIC FILE TECHNIQUE
 Jiffy Tube: Riffcin In 1980

 Plugging action with WET COTTON PELLET by  Incremental Filling Technique: Gould In 1972
Donnenberg (1974)
 Lentulospiral Technique: Kopel In 1970.
 ENDODONTIC PRESSURE SYRINGE: Greenberg
and Spedding ( 1965 )  Amalgam Plugger : Nosonwitz In 1960 And King 1984

LESION STERILIZATION AND TISSUE Apexogenesis

REPAIR THERAPY( LSTR)
 LSTR 3Mix-MP therapy is a novel caries, pulpal and root canal  encourage continued physiological development and
treatment system. Using an anti-bacterial drug combination, the
therapy aims to eliminate causative bacteria from lesions, and after formation of root end
sterilization, the lesions are repaired or regenerated by the host’s
natural tissue recovery process.  preserve the vitality of pulp, & increase the thickness of
radicular dentinal wall
 COMPOSITION  to generate dentinal bridge at the site of placement of
 Tab.Ciprofloxacin 500 mg calcium hydroxide
 Tab. Metronidazole 400 mg
 Cap. Minocycine 100 mg

Carrier (MP)
 Macrogol ointment
 Propylene glycol
 Antibiotics (3Mix) 1:1:1 ratio or 1:3:3

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Apexification
Indications:  Objective is to induce root end closure of
immature roots
 Traumatized or pulpally involved permanent tooth when
root apex is incompletely formed
 no post-treatment adverse clinical signs or
 No H/O spontaneous pain symptoms

 No sensitivity to percussion
 no abnormal canal calcification or internal and
external root resorption lateral root pathosis
 No hemorrhage

 Normal radiographic appearance  no breakdown of periradicular supporting tissues

Materials

Apexification Procedure  Ca(OH)2 + sterile water

 Ca(OH)2+CMCP

 Antibiotic paste

 Corticosteroid paste
Apical closure Apical barrier
 Calcium phosphate gel
technique technique
 osteogenic protein

 MTA

Semipermanent Restorations Ideal Requirements

GOAL
 To achieve biologically compatible, masticatorily
competent and clinically acceptable restoration.
 Represent natural tooth
 Match color of adjacent teeth
 Mesiodistal width in proportion

 Restore function and esthetics

 To maintain the form and function and where
possible, the viability of the tooth.  Maintain adequate arch length

 Biocompatible

 Economical

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Classification

According to form and contour: According to materials used:

 Stainless Steel Crowns.

 Untrimmed, uncontoured, uncrimped crowns.  Nickel Chromium Crowns.
 Polycarbonate crowns.
 Pedo strip crowns.
 Pre-contoured and untrimmed crowns.

According to the location:

 Pretrimmed, precontoured and precrimped crowns.
 Crowns for anterior teeth.
 Crowns for posterior teeth

References
 Ingle : Endodontics.Ed 5th.Mosby

 Stainless steel crowns  Marwah N: Comprehensive Pediatric Dentistry.Ed 1st, 2006 Arora

 Open-face Steel Crowns.  Mathewson: Fundamentals of Pediatric dentistry. Ed. 2nd.

Quintessence

 Preveneered Steel Crowns  McDonald: Dentistry for the child and adolescent.Ed 8th, 2004.Mosby.

 Pinkham: Pediatric Dentistry-infancy through adolescence. Ed 4th,

 Polycarbonate Crowns. 2005.Saunders.

 Naik S, Hegde A M: Mineral trioxide aggregate as a pulpotomy agent

 Resin Crowns/ Celluloid crowns/ Composite Resin Strip in primary molars: An in vivo study. J Indian Soc Pedod Prev Dent
2005;23(1):13-16.
Crown/ Strip crowns.

 Cohen S : Pathways of the pulp. Ed 9th, 2006.Elsevier.

 Hutchins D W, Parker W A : Indirect pulp capping:clinical  Stainless steel crown in clinical pedodontics: a review. F Salama. The
evaluation using polymethyl methacrylate reinforced zinc oxide –
eugenol cement. J Dent Child 1972:Jan-Feb:55-56. Saudi Dental Journal, Volume 4, Number 2, May 1992

 Huth K C et al : Effectiveness of 4 pulpotomy techniques-

Randomized controlled trial. J Dent Res 2005;84(12):1144-1148.
 Ibricevic H, Al-Jame Q : Ferric sulphate and formocresol in
pulpotomy of primary molars : long term follow-up study. Eur J
Paediatr Dent 2003;4(1):28- 32.
 Efficacy of preformed metal crowns vs. Amalgam restorations in
primary molars: a systematic review . Ros C. Randall. J Am Dent
Assoc, vol 131, no 3, 337-343. 2000

 Finn S B : Textbook of Pedodontics.  A Comparison Between Preformed Stainless Steel Crowns and Simple
Restorations On Primary Molars In A Public Health Dental Program.
 Grossman : Endodontic Practice.Ed 11th,1988.Varghese. Middle east journal of family medicine. June 2008 - Volume 6, Issue 5

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 UK National Clinical Guidelines in Paediatric Dentistry:

stainless steel preformed crowns for primary molars. S. A.
Kindelan International Journal of Paediatric Dentistry 2008;
18 (Suppl. 1) : 20–28

 Dental Cements for Definitive Luting: A Review and Practical

Clinical Considerations Edward E. Hill. Dent Clin N Am 51
(2007) 643–658

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