Clinical Cases in Pediatric Dentistry 1st Edition PDF Chapter 3

3 Complex Pulp Therapy Anna B. Fuks Case 1: Indirect Pulp Treatment........................................ 90 Evelyn Mamber Case 2: Partial Pulpotomy in Traumatized Primary Incisors........................ 95 Etty Dayan, Diana Ram, and Anna B. Fuks Case 3: Cervical Pulpotomy in Cariously Exposed Pr...

3 Complex Pulp Therapy Anna B. Fuks Case 1: Indirect Pulp Treatment........................................ 90 Evelyn Mamber Case 2: Partial Pulpotomy in Traumatized Primary Incisors........................ 95 Etty Dayan, Diana Ram, and Anna B. Fuks Case 3: Cervical Pulpotomy in Cariously Exposed Primary Molars................... 101 Moti Moskovitz and Anna B. Fuks Case 4: Root Canal Treatment in a Primary Molar............................. 106 Moti Moskovitz Case 5: Partial Pulpotomy in a Cariously Exposed Young Permanent Molar.............. 111 Moti Moskovitz and Anna B. Fuks Case 6: Pulpotomy with MTA in an Immature Permanent Molar.................... 115 Zvia Elazary and Ilana Heling Case 7: Root End Closure—Apexification with Ca(OH)2.......................... 120 Iris Slutzky-Goldberg Case 8: Root End Closure with MTA.................................... 126 Iris Slutzky-Goldberg Case 9: Revascularization of Necrotic Immature Permanent Tooth with Apical Periodontitis..... 131 Eyal Nuni Clinical Cases in Pediatric Dentistry, First Edition. Edited by Amr M. Moursi. © 2012 Blackwell Publishing Ltd. Pubished 2012 by Blackwell Publishing Ltd. 89 CHAPTER 3 Case 1 Indirect Pulp Treatment A B Figure 3.1.1a–b. Facial photographs A. Presenting Patient 6-year-, 6-month-old Hispanic female Recall visit two years after last appointment B. Chief Complaint and History of Present Injury Patient’s father stated that his daughter “complained of toothache the last few days in the lower back right side, and I can see she has several cavities. She has not been to the dentist for a long time.” FUNDAMENTAL POINT 1 Questions to Ask When Obtaining a History Regarding Pain Describe the pain. Does it linger or subside after stimulus is removed? Is the pain spontaneous? What are the frequency, severity, duration, triggering agents of the pain (thermal, food, sleeping)? What are the symptoms (fever, swelling)? What has been the analgesic use? 90 Clinical Cases in Pediatric Dentistry C. Social History Middle class Patient is in 1st grade D. Medical History No significant findings, no known drug or food allergies, no medications, vaccinations are up to date E. Medical Consult N/A F. Dental History Dental home was established at the age 16 months when initial signs of early childhood caries were observed on the maxillary primary incisors. Fluoride varnish applications were recommended every three months at that time Despite recommendation for routine six-month recalls, two years have passed since last visit Cariogenic diet Poor oral hygiene, brushes once daily, unsupervised Uses toothpaste containing fluoride Lives in an optimally fluoridated area No history of dental/oral trauma Cooperative behavior for all past dental care G. Extra-oral Exam No significant findings H. Intra-oral Exam Soft Tissues No significant findings Hard Tissues No significant findings Occlusal Evaluation of Primary Dentition Mesial step molars, class III right canines, class I left canines COMPLEX PULP THERAPY Other Moderate plaque accumulation Several teeth with moderate to extensive carious lesions Mandibular right primary second molar with an extensive carious lesion I. Diagnostic Tools Periapical radiograph of the mandibular right primary second molar at the time of the initial appointment (Figure 3.1.2) shows a large occlusal carious lesion. It was treated with a pulpectomy as an emergency Right and left bitewing radiographs were taken after the initial visit, which focused on emergency treatment of the mandibular right primary second molar (Figures 3.1.3 a, b) The bitewing radiographs showed deep carious lesions on the maxillary right primary second molar and on the mandibular left primary second molar (Figure 3.1.3.) J. Differential Diagnosis For the Maxillary Right and the Mandibular Left Primary Second Molars: Deep carious lesions with possible pulp involvement Figure 3.1.2. Pre-op periapical radiograph of the mandibular right primary second molar A B Figure 3.1.3a–b. Bitewing radiographs after pulpectomy and prior to IPT treatments. A. Right bitewing radiograph, B. left bitewing radiograph Deep carious lesions with partial necrosis Deep carious lesions with total necrosis K. Diagnosis and Problem List Diagnosis Extensive carious lesions in several primary molars Deep carious lesion on the right mandibular second primary molar (treated with a pulpectomy in the initial appointment as an emergency) Maxillary right and mandibular left primary second molars with deep carious lesions without signs or symptoms of irreversible pulpits and no soft tissue pathology No radiographic signs of pulpal nor peri-radicular pathology Problem List High caries risk due to several factors: cariogenic diet, poor oral hygiene, moderate plaque accumulation, unsupervised brushing, no regular dental visits Several untreated carious lesions with possible reversible and/or irreversible pulp involvement L. Comprehensive Treatment Plan Emergency treatment of the right mandibular primary second molar Explanation to the father of the importance of maintaining a primary second molar, particularly prior to the eruption of the first permanent molar Indirect pulp treatment (IPT) technique was chosen for the deep lesions of the maxillary right and mandibular left primary second molars, considering that they were asymptomatic and amenable to be properly sealed with leakage-free restorations Comprehensive treatment of other carious lesions: Consider using nitrous oxide analgesia given the length of the procedures Follow up care including: Immediate post-op and home care instructions Prevention plan Recall visits every three months, including fluoride varnish application and caries risk re-evaluation Follow up radiographs after six months IPT Technique Local anesthesia and rubber dam Caries removal leaving affected dentin over the pulpal floor Coverage of the affected dentin with glass ionomer cement. This material was chosen due to its Clinical Cases in Pediatric Dentistry 91 CHAPTER 3 BACKGROUND INFORMATION 1 Indirect Pulp Treatment Indirect pulp treatment (IPT) is recommended for teeth that have deep, carious lesions approximating the pulp but without signs or symptoms of pulp degeneration. In this procedure, the deepest layer of the remaining carious dentin is covered with a biocompatible material to prevent pulp exposure and additional trauma to the tooth. This results in the deposition of tertiary dentin, which increases the distance between the affected dentin and the pulp, and in the deposition of peritubular (sclerotic) dentin, decreasing dentin permeability. It is important to remove the carious tissue completely from the dentino-enamel junction (DEJ) and from the lateral walls of the cavity to achieve optimal interfacial seal between the tooth and the restorative material, thus preventing microleakage. The dilemma that clinicians face lies in the assessment of how much caries to leave on the pulpal or axial floor. The carious tissue that should remain on the floor of the cavity preparation is a A B Figure 3.1.4a–b. Post-IPT bitewing radiographs. A. Post-op right bitewing radiograph, B. Post-op left bitewing radiograph biocompatible properties, ability to promote remineralization of the demineralized dentin, and fluoride release capacity Both teeth received a Class I restoration using a composite resin material followed by a fissure sealant M. Clinical and Radiographic Follow-up Ten months after IPT on the maxillary right primary second molar (Figure 3.1.4a) and on the mandibular left primary second molar (Figure 3.1.4b). Notice the retraction of the distal pulp horn due to the formation of reactionary dentin on both teeth 92 Clinical Cases in Pediatric Dentistry quantity that, if removed, would result in overt exposure. It is difficult to determine whether an area is an infected carious lesion or a bacteria-free demineralized zone. The best clinical marker is the quality of the dentin: soft, mushy dentin should be removed, and hard, discolored dentin can be indirectly capped. The ultimate objective of this treatment is to maintain pulp vitality by: Arresting the carious process Promoting dentin sclerosis (reducing permeability) Stimulating the formation of tertiary dentin Remineralizing the carious dentin. Two materials have been most commonly used in IPT: Ca(OH)2 and zinc oxide–eugenol paste. Lately, glass ionomer cements have also been successfully used in this procedure. Massara, Alves, and Brandao (2002) demonstrated that glass ionomer creates conditions that lead to remineralization and recommended it as a good base for IPT. N. Prognosis and Discussion Prognosis for caries: The recommended protocol for decreasing caries risk depends on the parents’ understanding and compliance in reducing the identified risk factors and in attending regular recall exams. In the present case, the parent brought the child for a recall visit 10 months after the completion of the initial comprehensive dental treatment, instead of the recommended six months. At that time, new lesions were identified Prognosis for IPT: The prognosis for IPT is usually good. Partial caries removal in asymptomatic primary or permanent teeth reduces the risk of pulp exposure. Success rates of IPT have been reported to be higher than 90% in primary teeth; thus, its use is recommended in patients in whom a pre-operative diagnosis suggests no signs of pulp degeneration. The value of taking a good history complemented by a careful clinical and radiographic examination cannot be overestimated. Studies investigating the long-term outcome of partial caries removal have used either composite resins COMPLEX PULP THERAPY or stainless steel crowns as the restorative material. A recent systematic review of the literature (Ricketts et al. 2006) reported no difference in the incidence of pulp exposure, in the progression of the decay and on the longevity of restorations, irrespective of whether the removal of decay had been minimal (ultraconservative) or complete. In the present case, the longevity of the composite restoration also depends on a periodic clinical follow-up to check the integrity of the margins of the restoration to rule out microleakage. In addition, the presence of a new proximal lesion might jeopardize the success of the IPT by contamination of bacteria and/or their toxins. Therefore, in children with high caries risk, using a stainless steel crown over an IPT is suggested. The most relevant factor noted in the present case that can contribute to a poor prognosis is the patient’s lack of compliance with dental appointments O. Common Complications and Alternative Treatment Plans The most common complications of a failing IPT are pulp necrosis and/or a periapical lesion. These may be the result of an initial misdiagnosis of an irreversibly inflamed or necrotic pulp or due to a poor restoration leading to microleakage. Alternative treatments include pulpotomy or pulpectomy Self-study Questions 1. What could have prevented the amount and severity of the carious lesions in the present case? 2. Could a sealant have prevented these lesions? 3. Has the adopted approach to prevent pulp exposure (IPT) been evaluated and supported by the literature? 4. When is an IPT contraindicated for primary molars? 5. Should poor compliance and high caries risk influence the choice of treatment? Bibliography and Additional Reading Ricketts DNJ, Kidd EAM, Innes N, Clarkson J. 2006. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database of Systematic Reviews. Jul 19; 3:CD003808. Fuks AB. 2005. Pulp therapy for the primary dentition. In: Pediatric Dentistry, Infancy through Adolescence 4th Edition. Pinkham JR, Casamassimo PS, Fields HW Jr., McTigue DJ, Nowak AJ (eds). Elsevier Saunders: St. Louis. pp. 375–93. Massara MLA, Alves JB, Brandão PRG. 2002. Atraumatic restorative treatment: Clinical, ultrastructural and chemical analysis. Caries Res 36:430. Answers are located at the end of the case. Clinical Cases in Pediatric Dentistry 93 CHAPTER 3 SELF-STUDY ANSWERS 1. If the child’s parents would have had a better compliance and followed the six-month recall protocol, at least the severity of the lesions could be controlled and new lesions prevented 2. Probably yes. Sealants are indicated for primary and permanent teeth with pits and fissures that are predisposed to plaque retention. If the sealant covering the susceptible fissure is intact, it can definitely prevent the development of caries 3. Yes. A systematic review of the literature (Ricketts et al. 2006) reported no difference in the incidence of pulp exposure, in the 94 Clinical Cases in Pediatric Dentistry progression of the decay and on the longevity of restorations, irrespective of whether the removal of decay had been minimal (ultraconservative) or complete 4. IPT is contraindicated for primary molars when there is a history of spontaneous pain or any clinical and/or radiographic pathological signs. The tooth must be vital to be treated with IPT 5. Yes. In patients with high caries risk and poor compliance, it is preferable to use radical treatment approaches, such as stainless steel crowns, instead of multi-surface restorations COMPLEX PULP THERAPY Case 2 Partial Pulpotomy in Traumatized Primary Incisors F. Dental History Has dental home Eating habits include a balanced diet rich in proteins and low in carbohydrates. The child eats regular meals and the parents demand that their children limit the ingestion of sweets to after meals Fair oral hygiene habits, brushes twice daily with parental supervision Uses toothpaste containing fluoride Optimal water fluoridation levels No history of previous trauma G. Extra-oral Exam Mild swelling of the upper lip Figure 3.2.1. Facial photograph A. Presenting Patient 4-year-, 2-month-old Caucasian female New patient presenting as an emergency B. Chief Complaint Mother stated, “My daughter fell while playing with other children in the kindergarten yard and fractured her two upper front teeth” C. Social History Second of three children Both parents are well educated Middle class, mother works part time D. Medical History No significant findings, no known food or drug allergies, no medications, vaccinations are up to date E. Medical Consult N/A H. Intra-oral Exam Soft Tissues Bruises on labial mucosa, gingival laceration on maxillary anterior area, and laceration of the labial frenum Hard Tissues No significant findings Occlusion Evaluation of Primary Dentition Mesial step molars, class I canines Other Moderate plaque accumulation over the fractured teeth Caries-free primary dentition Maxillary central incisors with complicated crown fractures Mild sensitivity to percussion on both maxillary central incisors Physiologic mobility on both traumatized incisors Extremely apprehensive Clinical Cases in Pediatric Dentistry 95 CHAPTER 3 FUNDAMENTAL POINT 1 Complicated Crown Fracture Definition: Enamel-dentin fracture with pulp exposure Figure 3.2.2. Anterior maxillary periapical radiograph showing crown fractures with pulp involvement I. Diagnostic Tools Anterior maxillary periapical radiograph (Figure 3.2.2). Bitewing radiographs were not taken because the patient has periodical examinations at her family dentist J. Differential Diagnosis Complicated crown fractures of maxillary primary central incisors Complicated crown–root fractures Complicated crown fractures associated with subluxation K. Diagnosis and Problem List Diagnosis Based on the history of pain, clinical examination, and radiographic findings, the most probable diagnosis is complicated crown fractures of maxillary primary central incisors Problem List Maxillary primary central incisors with exposed pulps and pulp polyps needing emergency treatment Child has never had a local anesthetic L. Comprehensive Treatment Plan Emergency treatment of the exposed pulps Explanation to the mother of the importance of maintaining the vitality of both teeth Behavioral management considerations (consider using nitrous oxide analgesia) Follow-up care including: Post-op and home care instructions Recall plan Radiographs should be taken after 3, 6, 12, 18, and 24 months and thereafter at yearly intervals until physiologic exfoliation of the teeth M. Prognosis and Discussion Long-term studies have shown very high success rates of pulp capping and partial pulpotomy with 96 Clinical Cases in Pediatric Dentistry Diagnosis: Clinical and radiographic findings reveal a loss of tooth structure with pulp exposure Treatment objectives: Maintain pulp vitality and restore normal esthetics and function. Injured lips, tongue, and gingiva should be examined for tooth fragments. Pulpal treatment alternatives are pulpotomy, pulpectomy, and extraction Primary Teeth Keep treatment as simple as possible, taking into consideration the child’s behavior and the life span of the tooth. Decisions often are based on life expectancy of the traumatized primary tooth and vitality of the pulpal tissue Risk of treatment and possible sequelae to the permanent tooth should be assessed versus the functional benefit resulting from treatment to the primary tooth FUNDAMENTAL POINT 2 Advantages of Partial Pulpotomy Preserves cell-rich coronal pulp Increases healing potential due to preserved pulp Physiologic apposition of cervical dentin Obviates need for root canal therapy Preserves natural color and translucency Maintains pulp test responses respect to pulp survival. Radiographic evidence of hard tissue closure of the perforation can be seen three months after pulp capping. Most of the studies were done in permanent teeth The primary factor to pulp survival after crown fracture is compromised pulp circulation due to luxation injuries. Crown fracture with concomitant luxation injury has been shown to have an COMPLEX PULP THERAPY BACKGROUND INFORMATION 1 Partial Pulpotomy (Cvek Pulpotomy) Indications and Technique Indications: Traumatic Pulp Exposures Initially performed only in permanent teeth. Presently, there is enough evidence that this procedure can also be applied in primary teeth Technique After the diagnosis is completed, the tooth is anesthetized. If possible, pulpal procedures should always be performed under rubber dam isolation and aseptic conditions to prevent further introduction of microorganisms into the pulp tissues (Figure 3.2.3). Care must be taken when placing the rubber dam on a traumatized tooth. If any loosening of the tooth has occurred, the rubber dam clamps must be applied to adjacent uninjured teeth In traumatically exposed pulps, only tissue judged to be inflamed is removed. Cvek (1994) showed that with pulp exposures resulting from traumatic injuries, regardless of the size of the exposure or the amount of lapsed time, pulpal changes are characterized by a proliferative response with inflammation extending only a few millimeters into the pulp. When this hyperplastic, inflamed tissue is removed (about 2 mm), healthy pulp tissue is encountered. In teeth with carious exposure of the pulp, it may be necessary to remove pulp tissue to a greater depth to reach uninflamed tissue. The instrument of choice for tissue removal in the pulpotomy procedure is an abrasive diamond bur, using high speed with adequate water cooling. This technique has been shown to create the least damage to the underlying tissue. Care must be exercised to ensure removal of all filaments of the pulp tissue coronal to the amputation site; otherwise, hemorrhage will be impossible to control. sterile water to remove all debris; the water is removed by vacuum and cotton pellets (Figure 3.2.4). Air should not be blown on the exposed pulp, because it will cause desiccation and tissue damage. Hemorrhage is controlled by cotton pellets slightly moistened with saline (i.e., wetted and blotted almost dry) placed against the stumps of the pulp. Completely dry cotton pellets should not be used because fibers of the dry cotton will be incorporated into the clot and, when removed, will cause hemorrhage. Dry cotton pellets are placed over the moist pellets, and slight pressure is exerted on the mass to control the hemorrhage. Hemorrhage should be controlled in this manner within several minutes. It may be necessary to change the pellets to control all hemorrhage. If hemorrhage continues, the clinician must carefully check to be sure that all filaments of the pulp coronal to the amputation site were removed and that the site is clean. Sodium hypochlorite (2.5% NaOCl) can be placed on the exposure site to cause hemostasis before pulp capping. It also has the beneficial effect of killing bacteria. It was reported that when used as a hemostatic agent there was no damage to pulpal cells and it did not inhibit pulpal healing, odontoblastic cell formation, or dentinal bridging. If hemorrhage cannot be controlled, pulpal amputation should be performed at a more apical level. Once the hemorrhage is controlled, Ca(OH)2 or mineral trioxide aggregate (MTA) is placed in the canal against the pulp stump. A thin layer of intermediate restorative material or flowable composite resin is placed over the Ca(OH)2 or MTA and light cured (Figure 3.2.5); otherwise, the material would be washed out during the acid etching procedure. The tooth is then sealed with an etched bonded composite strip crown restoration (Figure 3.2.6). After pulpal amputation, the preparation is thoroughly washed with physiologic saline or Clinical Cases in Pediatric Dentistry 97 CHAPTER 3 Figure 3.2.3. Placement of rubber dam after administration of a local anesthetic Figure 3.2.5. After hemostasis, the amputated areas are covered with calcium hydroxide or mineral trioxide aggregate, followed by intermediate restorative material Figure 3.2.4. After pulp amputation, the area is rinsed with saline, and hemostasis is achieved with cotton pellet pressure increased incidence of pulpal necrosis. Cvek (1994) reported 96% success with partial pulpotomy using Ca(OH)2 on traumatically exposed permanent pulps. Size of the exposure or time between injury and treatment was not critical as long as the superficially inflamed pulp tissue was removed before capping. These studies included both mature teeth and teeth with immature roots. Subsequent investigations have verified these findings. In a long-term follow-up study of partial pulpotomy in permanent teeth, those judged to be healed at three years remained healed 10 to 15 years later. Only in the last few years did partial pulpotomy with Ca(OH)2 or mineral trioxide aggregate (MTA) 98 Clinical Cases in Pediatric Dentistry Figure 3.2.6. Completed restorations showing good esthetic results. The pulps remained vital start to be used as treatment modalities for traumatized primary incisors with pulp exposure. This was probably due to the traditional belief that pulpotomy with Ca(OH)2 results in internal root resorption. Today we know that most pulp dressing agents can lead to this pathologic complication, and may be due to the condition of the exposed pulp. Because the pulp is normal in traumatized exposures (except for the exposure area), removing the affected tissue brings about a good prognosis. The recommended treatment for traumatized primary teeth with pulp exposure is pulpectomy and full coverage, stainless steel crown [SSC] or COMPLEX PULP THERAPY composite strip crown (see Chapter 4, Flowchart C). Most root canal filling pastes cause discoloration of the tooth that can be seen through the composite crown. In addition, the tooth becomes brittle and more prone to fracture. N. Complications and Alternative Treatment Plans Unsuccessful partial pulpotomy can result in pulp necrosis and/or a periapical abscess with or without a fistula. These complications can be the result of chronic irritation due to microleakage from an improperly adapted SSC or defective strip crown. Another reason for failure can be related to recurrent trauma, a relatively common finding in young children. These complications can also occur if the initial treatment was a pulpectomy and SSC. Extraction is an alternative, but less desirable in a young child Self-study Questions 1. What are the treatment objectives for a complicated crown fracture? 2. What is the treatment recommended by the American Academy of Pediatric Dentistry for a complicated crown fracture in a traumatized primary incisor? 3. According to Cvek, what are the pulpal changes resulting from a traumatic pulp exposure? 4. What are the advantages of using sodium hydrochloride (NaOCl) to control pulpal hemorrhage during a pulpotomy procedure? 5. What are the advantages of a partial pulpotomy over a pulpectomy for treatment of a complicated crown fracture? 6. What are the most commonly used pulp dressing materials in partial pulpotomy, and what are their properties? Bibliography and Additional Reading the Teeth, 3rd Edition. In: Andreasen JO, Andreasen FM (eds). Munksgaard: Copenhagen. Kupietzky A, Holan G. 2003. Treatment of crown fractures with pulp exposure in primary incisors. Pediatr Dent 25:241–48. Fuks AB, Heling I. Pulp therapy for the young permanent dentition. In: Pediatric Dentistry Infancy through Adolescence, 4th Edition. Pinkham JR, Casamassimo PS, Fields HW Jr., McTigue DJ, Nowak AJ (eds). Elsevier Saunders: St. Louis. Chapter 33. Casas M, Fuk AB. 2011. Pulp therapy in primary and young permanent teeth. In: The Handbook of Pediatric Dentistry, 4th Edition. Nowak AJ, Casamassimo PS (eds). American Academy of Pediatric Dentistry, pp. 91–8. Camp JH, Fuks AB. 2006. Pediatric endodontics: Endodontic treatment for the primary and young permanent dentition. In: Pathways of the Pulp, 9th Edition. Cohen S, Hargreaves KM (eds). Mosby Elsevier: St. Louis. Chapter 22. Cvek M. 1994. Endodontic management of traumatized teeth. Textbook and Color Atlas of Traumatic Injuries to Answers are located at the end of the case. Clinical Cases in Pediatric Dentistry 99 CHAPTER 3 SELF-STUDY ANSWERS 1. To maintain pulp vitality and restore normal esthetics and function 2. Pulpectomy followed by a SSC or a composite strip crown 3. Cvek has shown that with pulp exposures resulting from traumatic injuries, regardless of the size of the exposure or the amount of lapsed time, pulpal changes are characterized by a proliferative response with inflammation extending only a few millimeters into the pulp (Cvek, 1994) 4. NaOCl, when placed on the exposure site, causes hemostasis, has a beneficial effect of 100 Clinical Cases in Pediatric Dentistry killing bacteria, and does not damage the pulpal cells 5. Partial pulpotomy allows for the preservation of cell-rich coronal pulp, increases the healing potential due to preservation of the pulp, allows the physiologic apposition of cervical dentin, obviates the need for root canal therapy, and preserves the natural color and translucency 6. Calcium hydroxide and MTA. Both stimulate the healing of the pulp and the formation of a dentin bridge COMPLEX PULP THERAPY Case 3 Cervical Pulpotomy in Cariously Exposed Primary Molars A B G. Extra-oral Exam No significant findings H. Intra-oral Exam Soft Tissues Generalized gingivitis Figure 3.3.1a–b. Facial photographs A. Presenting Patient 5-year-, 6-month-old Hispanic female New patient presenting as an emergency B. Chief Complaint Mother confirmed the patient’s complaint of pain in the lower left quadrant while eating; it subsides after a few minutes without taking analgesics C. Social History Fourth of nine children Lower socio-economic status D. Medical History Review of medical history revealed no significant findings, no known drug or food allergies, no medications, vaccinations are up to date E. Medical Consult N/A F. Dental History No dental home Eating habits include a low-protein, highcarbohydrate diet Poor oral hygiene, brushes without supervision Uses toothpaste containing fluoride Optimal water fluoridation levels No history of trauma Seven-day history of pain without history of swelling or fever Hard Tissues No significant findings Occlusal Evaluation of Primary Dentition Mesial step molars and class I canines Other Extensive plaque accumulation Several teeth with extensive carious lesions: maxillary first primary molars, mandibular left first primary molars, maxillary lateral and central incisors I. Diagnostic Tools Periapical radiograph of the maxillary incisors (Figure 3.3.2.) Two bitewings (Figure 3.3.3.) Unable to obtain posterior periapical radiographs (uncooperative behavior for the periapical radiographs) Radiographic lesions on maxillary first and second primary molars, maxillary lateral and central incisors, left mandibular first primary molar, mandibular primary canines, and mandibular right first and second primary molars J. Differential Diagnosis Deep carious lesions Reversible pulp inflammation Irrreversible pulp inflammation Partial pulp necrosis Total pulp necrosis K. Diagnosis and Problem List Diagnosis Based on the history of pain, clinical examination, and radiographic findings, the most probable Clinical Cases in Pediatric Dentistry 101 CHAPTER 3 FUNDAMENTAL POINT 1 Pulpotomy In Primary Teeth Treatment Objectives Eradicate potential for infection Maintain tooth in a quiescent state Preserve space for underlying permanent tooth Retain primary tooth if permanent tooth is congenitally absent Indications for a Pulpotomy Tooth with deep caries without pulp exposure Figure 3.3.2. Periapical radiograph of the maxillary incisor Carious or traumatic pulp exposure with transitory thermal and/or chemical stimulated pain Physiologic mobility A B Normal soft tissues No percussion sensitivity (except in cases of food impaction) Intact continuous ligament space Figure 3.3.3a–b. Bitewing radiographs. A. Right bitewing radiograph, B. Left bitewing radiograph diagnosis for the left mandibular first primary molar is a deep carious lesions with reversible pulp inflammation Problem List Several untreated carious lesions High caries risk due to several factors (cariogenic diet, poor oral hygiene with extensive plaque accumulation) Lack of dental home L. Comprehensive Treatment Plan Urgent treatment of the left first primary molar with formocresol pulpotomy and stainless steel crown (SSC) Explanation to the mother of the importance of maintaining the primary molars for proper occlusion Comprehensive treatment of other carious lesions Follow-up care including: Post-op and home care instructions Caries prevention plan Appropriate prevention and recall plan M. Radiographic Follow-up Post-operative bite-wing radiographs (Figure 3.3.4.) 102 Clinical Cases in Pediatric Dentistry Intact periapical and/or furcation bone Confounding Factors in Diagnosis of Pulp Status Color of pulpal hemorrhage not a reliable indicator of pulp histological status Excessive bleeding is strongly correlated with degenerative changes One-third of teeth with carious pulp exposures have “normal” pulps One-third of teeth with deep caries with no pulp exposures have “abnormal” pulps N. Prognosis and Discussion The pulpotomy procedure is based on the rationale that the radicular pulp tissue is healthy or is capable of healing after surgical amputation of the affected or infected coronal pulp. The presence of any signs or symptoms of inflammation extending beyond the coronal pulp is a contraindication for a pulpotomy. In the present case, removing the soft and mushy dentin in the three first primary molars resulted in pulp exposure, and the teeth were treated with a formocresol pulpotomy and restored with SSCs The ideal dressing material for the radicular pulp should: COMPLEX PULP THERAPY BACKGROUND INFORMATION 1 Pulpotomy Technique for Primary Teeth Technique Excavate caries, amputate coronal pulp, achieve hemostasis, treat radicular pulp with medicament, restore with permanent restoration Formocresol (FC) Pulpotomy Dilute FC using one part FC to four parts vehicle (three parts glycerine: one part water) and apply for five minutes Dilution mixture settles out; re-mixing indicated Method of action: tissue fixation Histological zones in FC-treated radicular pulp Acidophilic zone: Fixation (coronal) Pale staining zone: Atrophy (middle) Broad zone of inflammatory cells (apical) Bactericidal 62% to 97% acceptable outcome No dentinal bridging, but calcific changes evident Persistent chronic inflammation Small risk of succedaneous tooth damage Exfoliation accelerated Cellular toxicity Immune sensitization risk Humoral and cell–mediated responses: Controversial Mutagenic and carcinogenic potential: Controversial Ferric Sulfate (FS) 15.5% in aqueous base, pH = 1 Method of action: Hemostatic, denatures protein, and forms ferric ion complex that occludes cut blood vessels A B Figure 3.3.4a–b. Post-op bitewing radiographs. A. Post-op right bitewing radiograph, B. post-op left bitewing radiograph Be bactericidal Be harmless to the pulp and surrounding structures Promote healing of the radicular pulp Not interfere with the physiologic process of root resorption A good deal of controversy surrounds the issue of pulpotomy agents, and, unfortunately, the “ideal” pulp dressing material has not yet been identified. The most commonly used pulp dressing material is formocresol (Buckley’s solution: formaldehyde, cresol, glycerol, and water). Clinical and radiographic studies have demonstrated that formocresol pulpotomies have success rates up to 97%. Although many studies have reported the clinical success of formocresol pulpotomies, an increasing body of literature has questioned the use of formocresol. (Fuks 2005) O. Common Complications and Alternative Treatment Plans Unsuccessful pulpotomy in a primary molar might result in internal resorption progressing into the bone, an interradicular pathological lesion, and/or a periapical abscess, with or without a parulis. In most of these situations, the teeth must be extracted. Shorter application time than FC (10 to 15 seconds) Equivalent outcome to FC Self-limiting internal resorption reported Mineral Trioxide Aggregate (MTA) Method of action: Mineralization, dental cement with discrete crystals and amorphous structure, pH = 12.5 Pulp canal obliteration common Equivalent outcome to FC Promising clinical results Clinical Cases in Pediatric Dentistry 103 CHAPTER 3 Self-study Questions 1. Which teeth are good candidates for pulpotomy? 2. What are the contra-indications for a pulpotomy? 3. What are the objectives of a pulpotomy? 4. What are the complications of a pulpotomy failure in a primary molar? 5. What are the desirable characteristics of an ideal pulp dressing? Bibliography and Additional Reading Fuks AB. 2005. Pulp therapy for the primary dentition. In: Pediatric Dentistry, Infancy Through Adolescence, 4th Edition Pinkham JR, Casamassimo PS, McTigue DJ, Fields HW Jr., Nowak AJ (eds). Elsevier Saunders: St. Louis. pp. 375–93. Casas M, Fuks A, 2007, Pulp therapy in primary and young permanent teeth, In: The Handbook of Pediatric Dentistry, American Academy of Pediatric Dentistry, 3rd Edition. Nowak, AJ, Casamassimo, PS (eds), American Academy of Pediatric Dentistry, Chicago, pg. 77–85. American Academy of Pediatric Dentistry. 2011–2012. Guideline on pulp therapy for primary and young permanent teeth. Reference Manual. pp.212–19. 104 Clinical Cases in Pediatric Dentistry Answers are located at the end of the case. COMPLEX PULP THERAPY SELF-STUDY ANSWERS 1. Teeth with carious or traumatic pulp exposure with transitory thermal and/or chemical stimulated pain, with physiologic mobility, normal soft tissues, no percussion sensitivity (except in cases of food impaction), intact continuous ligament space, and intact periapical and/or furcation bone 2. Teeth with carious or traumatic pulp exposure with spontaneous pain, persistent thermal and/or chemical stimulated pain, pathologic mobility, inflamed soft tissues, parulis, percussion sensitivity, widened and/or discontinuous ligament space, furcation and/or periapical radiolucencies, external and/or progressive internal resorption, dystrophic intrapulpal calcifications, less than one-third physiologic root resorption 3. To maintain tooth vitality and to cause no harm to the succedaneous tooth 4. Unsuccessful pulpotomy in a primary molar might result in internal resorption progressing into the bone, in an inter-radicular pathological lesion, and/or a periapical abscess, with or without a parulis 5. The ideal dressing material for the radicular pulp should be bactericidal, harmless to the pulp and surrounding structures, promote healing of the radicular pulp, and not interfere with the physiologic process of root resorption Clinical Cases in Pediatric Dentistry 105 CHAPTER 3 Case 4 Root Canal Treatment in a Primary Molar E. Medical Consult N/A F. Dental History No dental home Was taken for the first time to a dental office for an emergency visit the day before and antibiotics were prescribed Poor oral hygiene habits Low-protein, high-carbohydrate diet Uses toothpaste containing fluoride Optimal water fluoridation levels No history of trauma G. Extra-oral Exam No significant findings Figure 3.4.1. Facial photograph A. Presenting Patient 5-year-, 2-month-old Hispanic female New patient presenting as an emergency B. Chief Complaint Mother stated that the child “had excruciating pain awaking her from sleep last night, and the gums close to the right lower back tooth were swollen and red.” C. Social History Seventh of 10 children Lower socio-economical status D. Medical History Review of medical history revealed congenital deafness, no known drug or food allergies, no medications, vaccinations up to date 106 Clinical Cases in Pediatric Dentistry H. Intra-oral Exam Soft Tissues Swelling and redness around lower right primary second molar Hard Tissues No significant findings Occlusal Evaluation of Primary Occlusion Vertical terminal plane (P) flush occlusal pattern Other Moderate plaque accumulation Several teeth with extensive carious lesions I. Diagnostic Tools Two bitewing radiographs Anterior periapical (maxillary) radiograph Periapical radiograph of lower right second primary molar Parent brought radiographs taken at another dentist’s office the day before; radiographs show extensive pathological radiolucency in the inter-radicular area of the lower right second primary molar COMPLEX PULP THERAPY J. Differential Diagnosis Acute dento-alveolar abscess Periodontal abscess Periapical granuloma Dentigerous cyst Radicular cyst K. Diagnosis and Problem List Diagnosis Deafness Based on the history of pain, the clinical examination, and the radiographic findings, the most probable dental diagnosis is acute dentoalveolar abscess in the lower right second primary molar Extensive caries lesions in other primary teeth Problem List High caries risk due to several factors (cariogenic diet, poor oral hygiene with moderate to extensive plaque accumulation, special health care needs) Several untreated carious lesions Lack of a dental home Extremely apprehensive L. Comprehensive Treatment Plan Emergency treatment of abscessed tooth (extraction or root canal treatment [RCT]) Explanation to the mother of the importance of maintaining a second primary molar, particularly prior to the eruption of the first permanent molar, focusing on the difficulty of placing and maintaining a distal shoe Behavioral management considerations (consider using nitrous oxide) Comprehensive treatment of other carious lesions Follow up care including: Post-op and home care instructions Prevention plan Recall plan, including any necessary consultations (orthodontic, endodontic, oral surgery, etc.) M. Radiographic Follow-up See Figures 3.4.2 to 3.4.5 N. Prognosis and Discussion Taken from Fuks (2005) The goal of pulpectomy is to maintain primary teeth that would otherwise be lost. The pulpectomy procedure is indicated in teeth that show evidence of chronic inflammation or necrosis Figure 3.4.2. Radiograph, immediate post root canal treatment (RCT). Notice extensive pathologic radiolucent inter-radicular area Figure 3.4.3. 15 months post-op radiograph. Notice interradicular area has healed with bone apposition Figure 3.4.4. 4 years and 8 months post-RCT showing treatment success Figure 3.4.5. Radiograph showing fully erupted premolar in appropriate occlusion in the radicular pulp, in teeth with carious exposure in which the radicular pulp exhibits clinical signs of hyperemia following coronal pulp amputation, or in teeth with evidence of necrosis of the radicular pulp, with or without caries involvement Conversely, pulpectomy is contraindicated in cases of infection involving the crypt of the succedaneous tooth, in teeth with non-restorable crowns, with perforation of the pulpal floor, with internal Clinical Cases in Pediatric Dentistry 107 CHAPTER 3 BACKGROUND INFORMATION 1 Root Canal Treatment in Primary Molars Root canal treatment (RCT) can be performed in primary molars with irreversible pulpitis, determined as continuous bleeding exceeding five minutes, dark to purple blood color, or pulp necrosis. Although color of the pulpal hemorrhage alone is not a reliable indicator of pulp status. Radiographic periapical or inter-radicular radiolucencies, without involvement of the follicle of the permanent tooth, are not considered contraindication for RCT. The same is true for teeth with internal resorption without perforation and for those with external resorption not involving the permanent tooth follicle, as long as more than two-thirds of the root is intact Technique RCT is usually completed in one visit. Under local anesthesia and rubber dam isolation, caries is removed and access to the pulp chamber is gained. The inflamed or necrotic pulp is then removed and mechanical preparation of the canal is performed using a series of 21-mm K-type endodontic files (Unitek Corp., Monrovia, CA) up to file no. 30. The working length is estimated from the preoperative radiograph. The root canals are then irrigated with alternating chlorhexidine or sodium hypochloride and saline, and dried with paper points. Because the morphology of the root canal system in primary teeth is extremely complex and difficult to clean mechanically, chemical disinfection is more effective. A root canal filling material containing iodoform is introduced into the root canal using a lentulo spiral mounted on a slow speed hand-piece, and the teeth are sealed with reinforced zinc oxide eugenol (ZOE) resorption perforating into the underlying bone, and with external resorption of more than one-third of the root However, there is disagreement among clinicians about the utility of pulpectomy procedures in primary teeth. Difficulty in the preparation of primary root canals that have complex and variable morphologic features and the uncertainty about 108 Clinical Cases in Pediatric Dentistry A postoperative radiograph is taken after each treatment to determine the extent of the filling material in the canals. “Flush” is determined when the filling material reaches the apex of the roots without excess beyond the apex, “underfilling” when the filling material is short of the apex, and “overfilling” when the filling material is extruded beyond the apex. Overfilling canals tend to result in more failures of the RCT. The patient is asked to return up to one month later for coronal restoration. In the absence of clinical pathologic signs of inflammation, the root-treated primary molars are restored with an amalgam or composite restoration if sufficient tooth structure remains to allow retention of the restoration. Otherwise, a stainless-steel crown is used. The estimated time left till natural shedding, determined by the extent of physiologic root resorption, also may influence the type of restoration to be placed. This factor, however, has less influence on the selection of the type of restoration. Evaluation of RCT Patients should return every six months for recall examinations, in which the root-treated molars are evaluated clinically and radiographically. RCT is considered successful if the tooth is painless and presents healthy surrounding soft tissues and normal mobility, and if radiographs show decrease or no change in the pre-existing pathologic radiolucent defects. The treatment is considered a failure when pre-existing radiolucent defects grow in size or new defects appear. Moskovitz, Sammara, and Holan (2005) showed that although not statistically significant, overfilling resulted in more failures than underfilling. teeth with gross loss of root structure; advanced internal or external or periapical resorption; and the effect of instrumentation, medication, and filling materials on developing succedaneous teeth dissuade some clinicians from using the technique. The behavior management problems that sometimes occur in pediatric patients have surely added to the reluctance among some dentists to COMPLEX PULP THERAPY perform RCT in primary teeth. These problems notwithstanding, the success of pulpectomies in primary teeth has led most pediatric dentists to prefer them to the alternative of extractions and space maintenance. Certain clinical situations may justify pulpectomy even with the knowledge that the prognosis may not be ideal. An example of such a case is pulp destruction of a primary second molar that occurs before the first permanent molar erupts. A premature extraction of the primary second molar without placement of a space maintainer usually results in mesial eruption of the first permanent molar with subsequent loss of space for the second premolar. Although a distal shoe space maintainer could be used, maintaining the natural tooth is definitely the treatment of choice. Therefore, a pulpectomy in a primary second molar is preferable, even if that tooth is maintained only until the first permanent molar has adequately erupted and is followed eventually by extraction of the primary second molar and placement of a space maintainer. O. Common Complications and Alternative Treatment Plans Enlargement of a previously existing periapical or inter-radicular radiolucency and the development of a new lesion in a tooth without a pre-operative pathologic radiolucency are real failures and should eventually be extracted. However, in cases in which the pre-operative radiolucency remains unchanged, the patient should be recalled in six months for re-evaluation. Unsuccessful root canal treatment in a primary tooth may result in its premature exfoliation due to pathologic root resorption that can be followed by premature eruption of the permanent successor. Cystic lesions have been described less frequently as complications of primary root canal treatments The dentigerous cyst is an uncommon complication of root canal treatment in primary molars. The cystic lesion in Figure 3.4.6 was observed six and a half years after the successful endodontic treatment presented above. Extraction of the exfoliating primary molar and marsupialization of the cyst resulted in normal eruption and occlusion of the permanent premolar Figure 3.4.6. Radiograph showing dentigerous cyst as a complication of root canal treatment in a primary molar Self-study Questions 1. What are the indications for a pulpectomy according to the Guidelines of the American Academy of Pediatric Dentistry? 2. When is a root canal treatment contra-indicated for primary molars? 3. What are the radiographic signs of root canal treatment failure, and how should they be handled? 4. According to Moskovitz, Sammara, and Holan (2005), which root-treated teeth are more prone to failure: the underfilled, flush, or overfilled? 5. What is more effective for disinfection of the root canal system in primary teeth: mechanical or chemical debridement? Answers are located at the end of the case. Clinical Cases in Pediatric Dentistry 109 CHAPTER 3 Bibliography Fuks AB. 2005. Pulp therapy for the primary dentition. In: Pediatric Dentistry, Infancy through Adolescence, 4th Edition. Pinkham JR, Casamassimo PS, McTigue DJ, Fields HW Jr., Nowak AJ (eds). Elsevier Saunders: St. Louis, pp. 375–93. Moskovitz M, Sammara E, Holan G. 2005. Success rate of root canal treatment in primary molars. J Dent 33:41–7. SELF-STUDY ANSWERS 1. In teeth with carious exposure in which the radicular pulp exhibits clinical signs of hyperemia or evidence of necrosis of the radicular pulp, with or without caries involvement, following coronal pulp amputation 2. In teeth with non-restorable crowns, with perforation of the pulpal floor, with internal resorption perforating into the underlying bone, with external resorption of more than one-third of the root, or involving the follicle of the permanent tooth 3. Enlargement of a previously existing periapical or inter-radicular radiolucency and the development of a new lesion in a tooth without 110 Clinical Cases in Pediatric Dentistry a pre-operative pathologic radiolucency are real failures and should eventually be extracted. However, in cases in which the pre-operative radiolucency remains unchanged, the patient should be recalled in another six months for re-evaluation 4. Although the differences were not statistically significant, overfilling resulted in more failures than underfilling or flush 5. Because the morphology of the root canal system in primary teeth is extremely complex and difficult to clean mechanically, chemical disinfection is more effective