Endodontics in primary molars

Question 1

what guidelines should you refer to for children with caries?

Answer 1

SDCEP guidelines

Question 2

what are the consequences of inadequate endodontic treatment?

Answer 2

• pain
• infection
• damage to permanent successor (hypomeralisation or hypoplastic)
• loss of space

Question 3

what are some features that should be considered in endodontics in primary molars?

Answer 3

• rapid caries progression
• small teeth have relatively large pulp chambers
• broader contact areas (greater SA for bacteria)
• irreversible pathological changes before pulp exposure
• early radicular pulp involvement

Question 4

when there is greater then 2/3 marginal ridge breakdown, what does it usually lead to?

Answer 4

• at least pulp horn inflammation
• increased likelihood of inflammation extending to the rest of the pulp and down the root

Question 5

how would you diagnose deep carious lesions in a primary molar?

Answer 5

• what symptoms from child
• what does parent report
• what can you see clinically
• what can you see radiographically

Question 6

what are the two techniques of removing deep caries in a primary molar?

Answer 6

• complete caries removal - results in pulp exposure - pulpotomy or direct pulp cap
• selective caries removal - leave affected dentine - place indirect pulp cap

Question 7

how does reversible pulpitis present in a child? how can you treat it?

Answer 7

• provoked pain for a short duration (5-10 mins) - biting, sweet foods
• initial stage of pulp inflammation can be treated with Hall crown, indirect pulp cap, pulpotomy

Question 8

what are indications for pulp treatment?

Answer 8

• excellent co-operation needed
• avoid GA
• medical history precludes extraction (bleeding disorder/coagulopathies)
• age of patient (under 9 years)
• ortho considerations - space considerations

Question 9

what are the contra-indications for pulp treatment?

Answer 9

• poor co-operation
• no LA = no pulp treatment
• medical history precludes pulp treatment (cardiac/immunocompomised)
• age of patient (very young or older than 9 - not enough roots left)
• ortho considerations - space closure desired
• severe/recurent pain
• space management
• advanced root resorption
• cellulitis
• pus in pulp chamber
• gross bone loss

Question 10

what are endodontic procedures for primary teeth?

Answer 10

• vital tooth - pulpotomy (partial removal of pulp)
• non-vital tooth - pulpectomy (full removal of pulp)

Question 11

what are clinical indications for vital pulpotomy?

Answer 11

• pulp minimally inflammed / reversible pulpitis
• marginal ridge destroyed
• caries extending greater than 2/3 into dentine on radiograph
• any doubt the pulp is exposed (caries, iatorgenic)

Question 12

what is the aim of a primary molar pulpotomy?

Answer 12

• stop bleeding
• disinfection
• preserve vitality of apical portion of radicular pulp

Question 13

describe the technique of a vital pulpotomy

Answer 13

• administer LA
• place dental dam and clamp
• access and remove gross caries
• remove roof of pulp chamber
• remove the coronal pulp
• achieve haemostasis - saline soaked cotton plaget or dry plaget, pressure for few mins
• place a calcium silicate cement over root stumps (MTA, biodentine)
• restore with GIC core or ZOE
• place a stainless steel crown

Question 14

what would you see if the pulp was uninflammed?

Answer 14

normal bleeding
* bright red colour
* good haemostasis

Question 15

what would you see if the pulp was unflammed?

Answer 15

abnormal bleeding
* deep crimson
* continued bleeding after pressure
* surting and cannot control
* if pulp does not bleed, it is dead

Question 16

what is shown here? what treatments can be done?

Answer 16

• abcess - pulp is non-vital
• treat by extraction or pulpectomy

Question 17

what are the signs of a non-vital primary molar?

Answer 17

• hyperaemic pulp - lots of bleeding
• no bleeding
• pulp necrosis and furcation involvement
• bone loss, root furcation

Question 18

what are the symptoms of a non-vital primary molar?

Answer 18

• child waking up in the middle of the night because of tooth
• unprovoked toothache
• irreversible pulpitis
• periapical pulpitis
• chronic sinusitis

Question 19

what is required for a primary molar pulpectomy? what is the aim?

Answer 19

• indication: excellent patient co-operation
• aim: prevent/control infection by extirpation (removal) of radicular pulp followed by cleaning and obturation of canals (filling and sealing)

Question 20

describe the technique of a primary pulpectomy

Answer 20

• administer LA
• place dental dam and clamp
• access and remove gross caries
• remove roof of pulp chamber
• remove the coronal pulp (extirpation)
• prepare the root canals but stop 2mm short of apex due to permanent tooth underneath
• obturate with CH/iodoform paste or ZO/idoform/CH pastes or ZOE paste (not gutta percha as does not resorb)
• GIC core
• place stainless steel crown

Question 21

what are clinical problems of endodontics in children?

Answer 21

• unexpected pulp exposure and no LA given
• inadequate anaesthesia when performing pulpotomy

Question 22

what is the process of controlling and preventing pain when pulp is exposed?

Answer 22

• place antibiotic/antiseptic dressing (Ledermix paste) over exposed pulp
• dress immediate restorative material (IRM) and review within 1 week
• complete pulpectomy once symptoms subside

Question 23

what are potential future complications of endodontics in children?

Answer 23

• can lead to early resorption, leading to early exfoliation (primary molars usually resorb at 7)
• over preparation e.g. may hit the developing tooth underneath

Question 24

how would you follow up pulp therapies?

Answer 24

• clinical review 6 monthly - check for clinical failure (pathological mobility, fistula/chronic sinus, pain)
• radiograph 12-18 monthly - check for radiographic faillure (increased radiolucency, external/internal resorption, furcation bone loss)