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7 • Paediatric Dentistry I
Box 7.5 Microabrasion Technique.
Armamentarium
n
Bicarbonate of soda/water
n
Fluoridated toothpaste
n
500 ppm fluoride mouthwash
n
Pumice
n
Rubber dam
n
Rubber prophylaxis cup
n
3M Sof-LexTM Contouring and polishing discs
n
Hydrochloric acid 6% or 37% phosphoric acid (etch)
Technique
1. Take preoperative vitality tests, photographs 1/– radiographs.
2. Isolate teeth to be treated with rubber dam.
3. Place a mixture of sodium bicarbonate and water on the dam
behind the teeth to protect in case of spillage.
4. Mix hydrochloric acid or phosphoric acid with pumice into a
slurry.
5. Apply a small amount to the labial surface on either a rubber
cup rotating slowly for 5 seconds or a wooden stick/flat plastic instrument rubbed over the surface for 5 seconds before
washing for 5 seconds directly into an aspirator tip. Repeat
until the stain has reduced, up to a maximum of ten 5-second
applications per tooth. Any improvement that is going to
occur will have done so by this time.
6. Apply 500 ppm fluoride mouthwash to the teeth for 3 minutes.
7. Remove the rubber dam.
8. Polish the teeth with the finest Soflex discs.
9. Polish the teeth with fluoridated toothpaste for 1 minute.
10. Review in 1 month for vitality tests and clinical photographs.
11. Review biannually, checking pulpal status.
Once completed, the procedure should not be repeated.
Too much enamel removal is potentially damaging to the
pulp and, cosmetically, the underlying dentine colour will
become more evident.
Indications
n
Fluorosis
n
Molar-incisor hypomineralisation
n
Idiopathic speckling
n
Postorthodontic demineralisation
n
Prior to veneer placement for well-demarcated stains
n
White/brown surface staining (e.g. secondary to primary
predecessor infection or trauma; Turner teeth)
Effectiveness
Critical analysis of the effectiveness of the technique should
not be made immediately but delayed for at least 1 month,
as the appearance of the teeth will continue to improve over
this time. Experience has shown that although white mottling is often incompletely removed, it does become less
perceptible. This phenomenon has been attributed to the
relatively prismless layer of compacted surface enamel produced by the ‘abrosion’ technique, which alters the optical
properties of the tooth surface.
Long-term studies of the technique have found no association with pulpal damage, increased caries susceptibility
or significant prolonged thermal sensitivity. Patient compliance and satisfaction are good, and any dissatisfaction is
usually a result of inadequate preoperative explanation.
The technique is easy to perform for operator and patient
and is not time-consuming. Removal of any mottled area is
permanent and is achieved with an insignificant loss of
surface enamel. Failure to improve the appearance by the
microabrasion technique does not have any harmful
effects and may make it easier to mask some lesions with
veneers.
Tooth whitening involves the chemical use of oxidation
agents to lighten tooth colour. Several bleaching agents
have been described in the past; however, 10% carbamide
peroxide is currently recommended for all techniques.
Carbamide peroxide gel (10%) breaks down in the mouth
into 3% hydrogen peroxide and 7% urea. Both urea and
hydrogen peroxide have low molecular weights, which allow them to diffuse rapidly through enamel and dentine.
This explains the transient pulpal sensitivity occasionally
experienced with bleaching systems for use at home.
The advantages of the home bleaching technique are:
n
easy for operator and patient
n
conserving of tooth tissue
n
maintenance of the original crown morphology.
Disadvantages are as follows:
n
There are strict regulations around the use of tooth
whitening products in the United Kingdom. The legal
position of tooth whitening must be taken into consideration when discussing these techniques with patients. This may preclude the use of bleaching agents
on patients under 18 years old.
n
The colour of restorations will remain unchanged after
bleaching and therefore these may need to be replaced.
n
Clinical studies have demonstrated that colour regression can be expected with this technique.
Side effects:
n
Sensitivity is the most common side effect reported.
Sensitivity is transient and resolves once treatment is
complete. Application of products containing casein
phosphopeptide-amorphous calcium phosphate (CPPACP, as found in GC Tooth Mousse) used within the
bleaching tray on alternative nights to bleaching can
help reduce this.
n
There is no evidence that bleaching itself significantly
affects the hardness of enamel; however, repeated access
to the root canal system for non-vital bleaching techniques could weaken the tooth structure.
n
Cervical resorption has been described as a side effect
when high concentrations of hydrogen peroxide or heat
are used for non-vital bleaching.
n
Reduction in the bond strength to composite occurs for
2 weeks after bleaching. Use of composite resin should
therefore be delayed over this period.
Non-vital bleaching is used for teeth that have become discoloured by the diffusion into the dentinal tubules of haemoglobin breakdown products from necrotic pulp tissue.
Prior to bleaching, radiographs should be taken to ensure
adequate root canal obturation and no sign of periapical
disease.
Master Dentistry
Indication
n
Discoloured non-vital teeth with a well-condensed guttapercha root filling and no clinical or radiographical signs
of periapical disease.
Contraindications
n
Heavily restored teeth
n
Staining from amalgam.
The following techniques can be considered to manage
non-vital discoloured teeth.
1. External bleaching
2. Internal bleaching – walking bleach technique
3. Combination of internal and external bleaching
a. Inside–outside open bleaching technique
b. Inside–outside closed bleaching technique
1. External bleaching
Bleaching agents have the ability to diffuse rapidly
through teeth when applied from the external surface. It has recently been suggested that external
bleaching should be considered as the first line of
treatment where the tooth has discoloured despite
adequate endodontic treatment, thorough debridement and restoration (Greenwal-Cohen and Green-
wall 2019). This can avoid repeated access to the pulp
chamber. Carbamide peroxide 10% should be applied
to the affected tooth via a specially constructed single
tooth bleaching tray.
2. Internal bleaching – non-vital walking bleach technique
This technique is described in Box 7.6. In this technique,
bleach is sealed into the pulp chamber following preparation. The bleach may need to be replaced over several
visits to reach the desired tooth shade. Once the correct
colour is established, the bleach is removed and the
tooth initially sealed with a temporary dressing prior to
definitive restoration with composite after a period of
. 2 weeks.
3. Inside–outside non-vital bleaching techniques
The inside–outside bleaching techniques involve construc-
tion of a single tooth bleaching tray to bleach the external tooth surface, while also bleaching internally from
the pulp chamber. 10% carbamide peroxide can be used
for each technique described.
The open inside–outside bleaching technique (IOO) is de-
scribed in Box 7.7. The access cavity is left open between
visits. Patients apply 10% carbamide peroxide into both
the open access cavity and the bleaching tray using the
supplied syringe before seating the tray. Bleaching agent
can be worn overnight or alternatively replaced every
4–6 hours. This is continued until the desired colour
change is obtained.
For the closed inside–outside bleaching (IOC) technique,
10% carbamide peroxide is sealed into the pulp chamber, as for the walking bleach technique (Box 7.6). The
patient then applies carbamide peroxide externally via
the bleaching tray each night until the tooth reaches the
desired colour change.
In comparison with the walking bleach technique, these
techniques allow the patient more control over the colour of the tooth. The closed technique avoids leaving an
open access cavity which risks food packing.
Box 7.6 Non-Vital Walking Bleach Technique.
Armamentarium
n
Rubber dam
n
Glass ionomer lining cement
n
10% carbamide peroxide gel
n
Cotton wool
n
White gutta-percha
n
Resin composite
Technique
1. Preoperative periapical radiographs are essential to check for
an adequate root filling.
2. Clean teeth with pumice, and make a note of the shade of
the discoloured tooth.
3. Place rubber dam isolating the single tooth. Ensure adequate
eye and clothing protection for the patient, operator and
dental nurse.
4. Remove palatal restoration and pulp chamber restoration.
5. Carefully remove root filling 2 mm below the level of the
dentogingival junction.
6. Place 1-mm glass ionomer cement over the gutta-percha.
7. Freshen dentine with a round bur. Do not remove excessively.
9. Fill the pulp chamber with 10% carbamide peroxide gel.
10. Place cotton wool roll over the caramide peroxide gel, and
seal the cavity with glass ionomer cement.
11. Repeat process at weekly intervals until the desired tooth
colour is established.
12. Place non-setting calcium hydroxide into the pulp chamber
for 2 weeks. Seal with glass ionomer cement.
13. Finally, restore the tooth with white gutta-percha (to facilitate
reopening pulp chamber again if necessary at a later date)
and resin composite.
Vital Bleaching
nightguard vital bleaching. The nightguard vital bleach-
ing technique involves the daily replacement of carbamide
peroxide gel into a custom-fitted tray of either the upper
and/or lower arch (Box 7.8). It demands a high degree of
patient compliance and motivation. Ideally, this technique
should be avoided in the mixed dentition, as teeth unerupted
at the time of bleaching will remain darker in colour. Its
main remit is in the older patient to treat the yellowing of
teeth.
Indications in Paediatric Dentistry
n
Mild fluorosis/MIH
n
Moderate fluorosis/MIH as an adjunct to microabrasion.
Recall
Patients should be recalled regularly (at least every week)
to monitor the success of the technique. For techniques
where bleach application is fully controlled by the patient
(vital bleaching, external bleaching and open inside–
outside bleaching), the patient should review tooth colour
each morning and cease bleaching once the desired colour
is achieved. Where bleach is sealed into the pulp chamber
(walking bleach and closed inside–outside bleaching), the
patient should be advised to contact the dental surgery if
they feel the desired colour has been reached before the
next scheduled review, to avoid overbleaching.
7 • Paediatric Dentistry I
Box 7.7 Non-Vital Inside–Outside Open
Armamentarium
n
Alginate impression compound
n
Rubber dam
n
Glass ionomer lining cement
n
10% carbamide peroxide gel
n
Cotton wool
n
White gutta-percha
n
Resin composite
Technique
1. Preoperative periapical radiographs are essential to check for
an adequate root filling.
2. Clean teeth with pumice, and make a note of the shade of
the discoloured tooth.
3. Take an alginate impression of the arch to be treated, and
cast a working model in stone.
4. Request a soft pulldown, vacuum-formed, non-reservoir
bleaching tray, no more than 2 mm in thickness which does
not cover the gingivae.
5. Place rubber dam isolating the single tooth. Ensure adequate
eye and clothing protection for the patient, operator and
dental nurse.
6. Remove palatal restoration and pulp chamber restoration.
7. Carefully remove root filling 2 mm below the level of the
dentogingival junction.
8. Place 1-mm glass ionomer cement over the gutta-percha.
9. Freshen dentine with a round bur. Do not remove excessively.
10. Instruct the patient how to apply the gel into the back of
their tooth and into their mouthguard.
11. The bleach should be applied each evening. The length of time
the guard should be worn depends on the product used. The
patient should check the colour of their teeth each day and
stop bleaching once the desired colour has been established.
12. Review the patient every 2 weeks. Once the desired colour has
been reached, place non-setting calcium hydroxide into the
pulp chamber for 2 weeks. Seal with glass ionomer cement.
13. Finally, restore the tooth with white gutta-percha (to facilitate
reopening pulp chamber again if necessary at a later date)
and resin composite.
Box 7.8 Nightguard Vital Bleaching Technique.
Armamentarium
n
Alginate impression compound
n
Carbamide peroxide gel 10%
Technique
1. Take an alginate impression of the arch to be treated, and cast
a working model in stone.
2. Request a soft pulldown, vacuum-formed, non-reservoir
bleaching tray, no more than 2 mm in thickness which does
not cover the gingivae.
3. Instruct the patient on how to floss their teeth. Perform a full
mouth prophylaxis, and instruct the patient how to apply the
gel into the mouthguard.
4. The length of time the guard should be worn depends on the
product used.
5. Review the patient about 2 weeks later to check that they are
not experiencing any sensitivity, and then at 6 weeks, by
which time 80% of any colour change should have occurred.
Effectiveness
Effectiveness can vary by the initial degree of discolouration with bleaching generally being less successful for teeth
which are more severely discolored.
For non-vital bleaching techniques, failure of a tooth to
bleach could be caused by inadequate removal of filling
materials from the pulp chamber. This should be checked
before abandoning a procedure.
Resin infiltration is a minimally invasive restorative treatment, which may have a role in the management of hypomineralised/decalcified lesions. Further research in this
area is required (Borges et al 2017).
Defective enamel can be replaced with a tooth-coloured
restoration that bonds to, and blends with, enamel
(Box 7.9). It is indicated for well-demarcated white, yellow
or brown patches.
The localised restoration is quick and easy to complete.
Advances in bonding and resin technology make these restorations simple and obviate the need for a full labial veneer.
Disadvantages are removal of tooth structure, marginal
staining and difficulty in achieving an accurate colour
match.
Although some form of porcelain restoration may be the
most satisfactory long-term restoration for a severely hypoplastic or discoloured tooth, it is not an appropriate
Box 7.9 Localised Resin Composite
Armamentarium
n
Rubber dam/contoured matrix strips
n
Round and fissure diamond burs
n
Enamel/dentine bonding kit
n
Hybrid resin composite
n
3M Sof-LexTM Contouring and polishing discs and
interproximal polishing strips
Technique
1. Take preoperative photographs, and make shade selection.
2. Apply rubber dam and contoured matrix strips.
3. Remove demarcated lesion with round diamond fissure bur.
4. Etch enamel margins, wash and dry as per the manufacturer’s
instructions.
5. Apply enamel and dentine bonding agent, and light-cure as
per the manufacturer’s instructions.
6. Apply chosen shade of composite using a brush lubricated
with the bonding agent to smooth and shape. Light-cure for
the recommended time.
7. Remove matrix strip/rubber dam.
8. Polish with graded Soflex discs (3M), finishing burs and interproximal strips if required. Add characterisation to surface of
composite.
9. Take postoperative photographs.
Master Dentistry
solution for children for two reasons: the large size of the
young pulp horns and chamber and the immature gingival contour.
Composite veneers may be direct (placed at initial appointment) or indirect (placed at a subsequent appointment having been fabricated in the laboratory). Composite veneers are
durable enough to last through adolescence (Box 7.10).
Indications
n
Discolouration
n
Enamel defects
n
Diastemata
n
Malpositioned teeth
n
Large restorations
Contraindications
n
Insufficient available enamel for bonding
n
Beware patients who play woodwind instruments!
Normally, porcelain veneers can be considered from 18 years
of age when the gingival margin is at an adult level and the
standard of oral hygiene is acceptable. Note, however, that
gingival changes can continue into the early 20s.
Box 7.10 Technique for Placement of Resin
Armamentarium
n
Rubber dam/contoured matrix strips
n
Preparation and finishing burs
n
Polishable hybrid resin composite
n
3M Sof-LexTM Contouring and polishing discs and interproximal polishing strips
Technique
1. Clean teeth with a slurry of pumice in water. Wash and dry,
and select shade.
2. Isolate the tooth with rubber dam, and place a contoured
matrix strip.
4. Etch the enamel as per the manufacturer’s instructions.
5. Where dentine is exposed, apply dentine primer.
6. Apply a thin layer of bonding resin to the labial surface with a
brush, and cure as per the manufacturer’s instructions. It may
be necessary to use an opaquer at this stage if the discolouration is intense.
7. Apply resin composite of the desired shade to the labial surface,
and roughly shape it into all areas with a plastic instrument
before using a brush lubricated with unfilled resin to ‘paddle’ and
smooth it into the desired shape. Cure 60 seconds gingivally,
60 seconds mesio-incisally, 60 seconds disto-incisally and 60 seconds from the palatal aspect if incisal coverage has been used.
Different shades of composite can be combined to achieve good
matches with adjacent teeth and a transition from a relatively
dark gingival area to a lighter, more translucent incisal region.
8. Flick away the unfilled resin.
9. Finish the margins with diamond finishing burs and interproximal strips and the labial surface with graded sandpaper discs.
Care should be taken to ensure composite at the gingival margin is smooth with no overhang. Characterisation should be
added to improve light reflection properties.
7.6 Tooth Surface Loss (Wear)
LEARNING OBJECTIVES
You should:
• be able to give accurate advice to patients/parents about
which foods and drinks can be harmful to the teeth
• be able to suggest suitable alternatives to the above
• know the medical causes of tooth surface loss (TSL)
• know the main treatment objectives for tooth surface loss
• know the appropriate materials to treat tooth surface loss.
Dentists have been aware of the problem of tooth wear or
non-carious loss of tooth tissue for a long time. However, it
is only more recently that it has been associated increasingly with our younger population. There are three processes that make up the phenomenon of tooth wear:
1. Attrition: wear of tooth as a result of tooth-to-tooth contact.
2. Erosion: irreversible loss of tooth substance brought
about by a chemical process that does not involve bacterial action.
3. Abrasion: physical wear of tooth substance produced by
something other than tooth-to-tooth contact.
In children, abrasion is relatively uncommon. The most
frequent cause of abrasion is overzealous toothbrushing,
which tends to develop with increasing age. Attrition during mastication is common, particularly in the primary
dentition, where almost all upper incisors show some signs
of attrition by the time they exfoliate. However, in the
1990s, the contribution of erosion to the overall process of
tooth wear in the younger population was highlighted.
While erosion may be the predominant process, attrition
and abrasion may be compounding factors (e.g. toothbrush
abrasion may be increased if brushing is carried out immediately after the consumption of erosive foodstuffs or drinks).
It is often difficult to identify a single causative agent in a
case of tooth wear, so the general term tooth surface loss may
be more appropriate.
There is very little published evidence on the prevalence or
severity of tooth wear in children. In 2013, the National
Child Dental Health Survey reported that 57% of 5-year-old
children had tooth surface loss of the palatal surfaces of
their primary incisors, with 16% showing progression into
the dentine or pulp. The prevalence of tooth surface loss
affecting the palatal surfaces of permanent incisors was
also alarmingly high, affecting 38% of 12-year-olds and
44% of 15-year-olds. This progressed into dentine or pulp
in 2% of 12-year-olds and 4% of 15-year-olds.
In young patients, there are three main causes of tooth
surface loss:
1. Dietary
2. Gastric regurgitation
3. Parafunctional activity
In addition to these, certain environmental factors have
been linked to tooth wear. With the exception of frequent
use of chlorinated swimming pools, most environmental
and occupational hazards do not apply to children.
The most common cause of erosive surface loss is excessive
intake of acidic food or drink. Food and drink implicated in
erosive tooth surface loss in young patients include:
n
acidic drinks (diluting juice, carbonated drinks, fruit juice)
n
citrus fruits (e.g. lemons, oranges, grapefruits)
n
tart apples
n
vinegar and pickles
n
yoghurt
n
fruit juices
n
vitamin C tablets.
Acidic drinks, in particular, are available to all age groups
of children. Pure ‘baby’ fruit juices are marketed for consumption by infants, and these have been shown to have pH
values below the critical pH for the dissolution of enamel
(pH 5.5). Many of these drinks are given to infants in a feeding bottle, and the combination of the highly acidic nature
of the drink and the prolonged exposure of the teeth to the
acidic substrate may result in excessive tooth surface loss as
well as dental caries. While a wide range of foods and drinks
is implicated in the aetiology of tooth surface loss, soft
drinks make up the bulk of the problem. Both normal and
so-called ‘diet’ carbonated drinks have very low pH values
and are associated with tooth surface loss, as are other fruit
juices and diluting juices. While there is no direct relationship between the pH of a substrate and the degree of tooth
surface loss, pH does give a useful indication as to the potential to cause damage. Other factors, such as titratable acidity, the effect on plaque pH and the buffering capacity of
saliva, will influence the erosive potential of a given substrate. In addition, it has been shown that erosive tooth
surface loss tends to be more severe if the frequency and
volume of drink consumed is high or if the intake occurs at
bedtime or during the night.
The pattern of dietary erosive tooth surface loss depends
on the manner in which the substrate is consumed. Carbonated drinks are commonly held in the mouth for some
time as the child ‘enjoys’ the sensation of the bubbles. This
habit may result in a generalised loss of surface enamel.
Generalised loss of surface enamel of posterior teeth is often
evident, particularly on the first permanent molars. Characteristic saucer-shaped lesions develop on the cusps of the
molars. This phenomenon is known as perimolysis.
7 • Paediatric Dentistry I
n
Chronic respiratory disease
n
Disease of the liver/pancreas/biliary tree
n
Overfeeding
n
Feeding problems/failure to thrive conditions
n
Reye’s syndrome
n
Rumination.
In addition, there is a group of patients that suffer from
gastro-oesophageal reflux disease (GORD). This may be either symptomatic, in which case the individual knows what
provokes the reflux, or the more insidiously asymptomatic
GORD, in which the patient is unaware of the problem and
continues to ingest reflux-provoking foods.
Localised tooth surface loss frequently occurs in patients
who exhibit abnormal parafunctional habits. The excessive
grinding that is a feature of this problem is not always apparent to the patient. However, apart from the marked
tooth tissue loss, other signs of bruxism may be evident including hypertrophy of the muscles of mastication, cheek
biting and tongue faceting. An example of erosion and
parafunction having a disastrous effect on the dentition
may be seen (and heard) in children who have cerebral
palsy. These children often have chronic gastric regurgitation and also severe bruxism, resulting in excessive tooth
surface loss.
n
Early recognition
n
Prevention advice
n
Monitoring
n
Temporary restoration
The most important part of management is early recognition and prevention. It is important to establish the aetiology
and, where possible, eliminate the cause.
Children with TSL should have a targeted prevention
regime as outlined in Section 7.4. In addition, particular
advice should be given relating to the consumption of
dietary acids and use of sugar-free chewing gum to
stimulate salivary flow. ‘Enamel care’ toothpastes and
age-appropriate high-fluoride toothpastes can be
considered.
Dietary counselling should be personal, practical and
positive. Suitable alternatives should be suggested, with the
most appropriate times for their intake:
The acidity of the stomach contents is below pH 1.0; therefore, any regurgitation or vomiting is potentially damaging
to the teeth. As many as 50% of adults with signs of tooth
surface loss have a history of gastric reflux. The aetiology of
gastric regurgitation may be divided into those with upper
gastrointestinal disorders and those with eating disorders.
In young patients, long-term regurgitation is associated
with a variety of underlying problems:
n
Gastro-oesophageal reflux
n
Oesophageal strictures
n
Inform patients of types of foods and drinks that have
greatest erosive potential.
n
Suggest plain water or milk as an alternative to acidic
drinks.
n
Limit the intake of acidic foods/drinks to meal times.
n
Use of a wide bore reusable straw held towards the back
of the mouth may help acidic drinks to bypass teeth.
However, paper straws which become saturated with
fluid on use are unlikely to be helpful.
n
Toothbrushing should be avoided immediately after consuming acidic food or drink.
Master Dentistry
Immediate temporary coverage of sensitive teeth with
GIC or composite resin can relieve symptoms and act as a
diagnostic aid.
Study models and clinical photographs can help monitor progression of TSL. These should be taken at initial
diagnosis and at periodic intervals to monitor progress.
The main treatment objectives are to:
n
resolve sensitivity
n
restore missing tooth structure
n
prevent further tooth tissue loss
n
maintain a balanced occlusion.
Ideally, aetiological factors should be identified and controlled prior to treatment.
In the primary dentition, if the child has experienced
no symptoms, the teeth can be monitored. If there are
associated symptoms, small areas of TSL can be restored
with composite, while larger areas can be restored
with composite crowns anteriorly and preformed metal
crowns posteriorly. Teeth with severe TSL, if associated
with spontaneous pain or signs of infection, may require
extraction.
The permanent dentition should also be managed conservatively where possible with composite addition to areas
of TSL. This can include placement of fissure sealants or
resin composite. Where resin composite is used, it can be
helpful to clean surfaces with pumice/water or gently
freshen the surface with a slow-speed rosehead bur to enhance resin infiltration into the sclerotic dentine and also to
use a dentine bonding agent to improve adhesion. During
growth, these restorations are well tolerated. Alternative
options may need to be considered where TSL is extensive.
Table 7.4 outlines treatment options for TSL in the primary
and permanent dentition.
Long-Term Review
Long-term review is necessary to:
n
reinforce prevention messages
n
monitor future tooth surface loss
n
maintain the existing restorations
n
provide support for the patient.
7.7 Endodontics
LEARNING OBJECTIVES
You should:
• know the indications and contraindications for primary
molar pulp treatment
• know the medicaments used in primary molar pulp
treatment
• know the treatment for vital and non-vital immature
permanent incisors
• know the initiating factors in the different types of
resorption.
The question of whether to retain primary teeth should
be based on three factors: medical, behavioural and
dental.
Medical, which may be contraindications to extraction of
primary teeth
n
Bleeding disorders and coagulopathies.
n
Hypodontia associated with syndrome (e.g. ectodermal dysplasia).
Medical indications for extraction of primary teeth
n
Congenital cardiac disease.
n
Immunosuppression.
n
Poor healing potential (e.g. unstable diabetes).
Behavioural reason for retention of primary teeth
n
Poor co-operation makes extraction difficult.
Behavioural reason for extraction of primary teeth
n
Need for dental general anaesthetic – depending on
available services.
Dental contraindications to extraction of primary teeth
n
Well-maintained arch.
n
Orthodontic considerations.
n
Hypodontia: lack of permanent successor.
Dental indications for extraction of primary teeth
n
Extensive caries with gross coronal breakdown, and
caries penetrating pulpal floor.
n
Acute infection.
n
Excessive tooth mobility.
n
Poorly maintained mouth.
Table 7.4 Treatment Technique for Tooth Surface Loss.
Dentition Anterior Posterior
Primary
dentition
Permanent
dentition
No treatment
Resin composite
restoration
Composite crowns
Extraction
Long-term monitoring
Fissure seal palatal
surface
Resin composite
restoration
No treatment
Resin composite
restoration
Preformed metal crowns
Extraction
Long-term monitoring
Resin composite
restoration
Preformed metal crown
Metal/composite onlay
Extraction
Vital Pulp Therapy for Primary Teeth:
Direct pulp capping
(Indirect pulp treatment)
Pulpotomy.
Non-Vital Pulp Therapy for Primary Teeth:
Pulpectomy.
Indications
n
Symptom-free tooth or transient pain of short duration,
suggesting reversible pulpitis
n
No sign of peri-radicular pathology
n
No clear radiographic barrier between caries and dental
pulp – precluding the use of the Hall technique.
7 • Paediatric Dentistry I
Isolation
Rubber dam should be used to aid isolation of teeth for pulp
therapy.
Indications
A small mechanical exposure on a vital symptom-free tooth
that is well isolated is the only situation where direct capping should be applied. If direct capping is applied in
other situations, pulp inflammation usually persists and
results in total pulp necrosis. In the majority of children,
pulpotomy is the preferred treatment, with a high rate of
success.
The aim of this treatment is to remove caries from the cav-
ity wall, leaving softened dentine over the pulp and avoiding pulpal exposure. The remaining softened dentine is
covered with setting calcium hydroxide to destroy any
remaining micro-organisms and to promote the deposition of reparative secondary dentine. This is then covered
with a glass ionomer lining and the tooth restored at the
same visit with a preformed metal crown.
Pulpotomy involves the amputation of vital inflamed pulp
from the coronal chamber as a means of preserving the
vitality and function of the remaining portion of radicular pulp (Fig. 7.1 and Box 7.11).
There remains some controversy over the most appropriate medicaments for use in vital primary molar pulpotomies.
Currently, ferric sulphate or mineral trioxide aggregate are
materials of choice. It is postulated that ferric sulphate
works by controlling pulpal bleeding and promotes formation of a ‘protective’ metal/protein clot over the underlying
Box 7.11 Technique for Vital Pulpotomy of a
1. A preoperative radiograph is taken of the affected tooth.
2. Use local anaesthesia and isolation.
3. Removal of caries and formation of an endodontic access
cavity.
4. Excavation of coronal pulp with slow-speed 6 or 8 bur or a
spoon excavator (see Fig. 7.1B).
5. Haemorrhage control. Place a cotton wool pellet soaked with
ferric sulphate into the excavated coronal pulp chamber.
Remove after 20 seconds: if bleeding persists, then repeat. If
bleeding is still a problem, it is likely that the radicular pulp
is inflamed and hyperaemic. At this point, pulpectomy or
extraction should be considered instead.
6. Restore pulp chamber with reinforced zinc oxide/eugenol
cement and reinforced glass ionomer cement (see Fig. 7.1D).
7. Restore the tooth with a preformed crown (see Fig. 7.1E).
8. MTA can be used as an alternative to ferric sulphate. If MTA is
to be used, bleeding in step 5 should be with a cotton wool
pellet soaked in saline. Once haemorrhage is controlled, MTA
can be placed to fill the pulp chamber. This is then lined with
glass ionomer cement and the tooth restored with a
preformed metal crown.
MTA, Mineral trioxide aggregate.
vital radicular pulp. Mineral trioxide aggregate (MTA) has
excellent bioactive properties and essentially stimulates cytokine release from pulpal fibroblasts, which in turn stimulates dental hard tissue formation. If successful, the treated
tooth should be asymptomatic. Failure will result in pain,
swelling, increased mobility, fistulae and radiographic signs
of either radiolucency at the furcation or apex or internal/
external resorption of the root.
Caries
Infected,
irreversibly
inflamed pulp
tissue
A
B
Zinc oxide/eugenol
cement
D
2001:171, Fig. 9.11. By permission of Oxford University Press, www.oup.com.)
Cotton wool moistened
with ferric sulphate
Slow-speed
round bur
C
Stainless steel
crown
E
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Radiographic assessment every 12 months is necessary
to check the above and the developing underlying permanent successor.
Non-Vital Pulp
Therapy for Primary Teeth:
Indications
n
Irreversible pulpitis.
Pulpectomy for Primary Teeth:
Pulpectomy involves the chemomechanical preparation of
primary root canals with endodontic hand instruments
and irrigants. Because of the anatomy of the root canals
and the presence of the permanent successor, greater
emphasis is often placed on the use of the antimicrobial
properties of the obturating material, especially in pri-
mary posterior teeth. Given the risk to the permanent
successor and the complex anatomy of the root canal
system, pulpectomy is rarely indicated in general practice.
The treatment of choice for the cariously exposed young
permanent tooth is dependent on:
n
stage of root development
n
status of the crown
n
orthodontic considerations for the tooth and the arch
n
The condition and presence of the remaining dentition.
n
psychological and behavioural factors.
The final decision has to balance the long-term advisability of retaining the tooth and the practicality of restoring
the crown. Consideration should be given to removal of
teeth with extensive caries and a guarded long term prognosis, particularly when there is potential for movement of
unerupted teeth into the resultant space or a tooth removal
is required for orthodontic purposes.
Options include:
Vital Pulp Therapy Immature Permanent Molars:
n
Indirect pulp treatment/step-wise caries removal
n
Direct pulp cap
n
Partial pulpotomy
Non-Vital Pulp Therapy for Immature Permanent Teeth:
n
Pulpectomy.
Calcium hydroxide cement is usually placed over the softened dentine but glass ionomer cement has also been
advocated. The ‘step-wise technique’ is described in more
detail in Section 7.4.
Direct Pulp Cap
Permanent teeth respond well to direct pulp capping proce-
dures, unlike primary teeth. Selection of appropriate
cases is important.
Indications
n
Small carious exposures
n
Teeth with no history of swelling or spontaneous pain
n
No radiographic changes
n
Controllable bleeding at exposure site.
Setting calcium hydroxide, MTA or biodentine can be
placed directly onto the exposed pulp, covered with a glass
ionomer cement and a definitive restoration placed.
Partial Pulpotomy
The aim of this treatment is removal of 1–3 mm inflamed
pulp tissue, with a clean round diamond high-speed bur,
beneath the site of a pulpal exposure leaving underlying
healthy pulp. Calcium hydroxide, MTA (at least 1.5 mm)
and biodentine are suitable materials for this technique to
promote bridge formation at the exposure site. These should
be lined with a glass ionomer liner prior to restoration of
the tooth, ideally at the same visit.
Non-vital teeth with immature roots often require to be removed, although short-term retention for orthodontic reasons may be desirable. After root canal instrumentation
and cleaning, a medicament such as non-setting calcium
hydroxide should be placed and the crown restored.
Permanent vital incisors can be treated with calcium hydroxide pulpotomy or Partial (Cvek) pulpotomy (apexogenesis).
The aim is removal of contaminated pulp tissue with a clean,
round, high-speed diamond bur in order to allow continued
root development and apical closure. (Fig. 7.2 and Box 7.12).
Success rate is 80–96%. Prognosis is best if the procedure is completed within 24 hours of exposure.
For vital teeth with immature roots, the aim of therapy is to
preserve vitality to ensure completion of root development.
As in the primary dentition, the tooth should be symptom
free or have transient pain of short duration, suggesting
reversible pulpitis, and there should be no sign of periapical
pathology. The need for pulp therapy can indicate a guarded
long-term prognosis, and therefore, as mentioned above,
the benefits and disadvantages of removal versus restoration should be considered.
Indirect Pulp Cap
An indirect pulp cap is indicated in teeth with minimal
symptoms. A thin layer of carious dentine is left over the
pulp because its removal would create an exposure.
Non-vital immature incisors with an open apex have no
apical barrier against which to condense conventional
obturation materials. Creation of an apical barrier (apexification) is therefore required prior to obturation. The most
appropriate way to achieve this is with MTA (Figure 7.3 and
Box 7.13). Use of non-setting Calcium Hydroxide to stimu-
late calcific barrier formation, was popular in the past but is
now rarely used given its long-term use makes the tooth
root brittle and liable to fracture.
Endodontic Treatment of Root Fractured Teeth:
Root canal therapy can often be confined to the non-vital
coronal portion of the canal. Instrumentation using hand
Non-setting
Apical
calcium
hydroxide
cement
Composite
resin
Hard-setting
cement
7 • Paediatric Dentistry I
Calcific barrier
formation
A
Press; 2001:173, Fig. 9.14, By permission of Oxford University Press, www.oup.com.)
B
C
Box 7.12 Pulpotomy of Vital Permanent Incisors.
1. Clinical examination (see Fig. 7.2A) shows a complicated fracture with microbial invasion of the coronal pulp. The pulp has
been exposed to the mouth for longer than 24 hours.
2. Use local anaesthesia.
3. Place rubber dam.
4. The coronal pulp is accessed with a diamond bur running at
high speed with constant water cooling (see Fig. 7.2B), and
pulp tissue excised with a slow-speed bur until healthy bleeding pulp is found. If there is excessive bleeding or no bleeding,
then continue to excise pulp tissue until all the coronal pulp is
removed.
5. Wash pulp with saline until haemorrhage stops. Remove any
clots with gentle saline washing. If pulp is either hyperaemic
or not bleeding once all coronal pulp has been removed, then
a pulpectomy and not a pulpotomy is required.
6. Non-setting calcium hydroxide is placed over pulp remnant.
Cover with setting calcium hydroxide and semipermanent
restorative material (see Fig. 7.2C).
7. Review at 6 weeks. If there is no evidence of pulp pathosis,
review at a further 6 weeks, and then 6 monthly for clinical
evaluation of pulp vitality and assessment of calcific bridge
formation, further root formation and signs of pathosis radiographically. Fig. 7.2D shows a calcific barrier with healthy pulp
at 12 months.
8. If vitality is lost, non-vital pulp therapy should be undertaken
through the calcific bridge.
9. Pulpectomy when root development is complete may be
required if the root canal is required for restorative purposes.
A modified Cvek pulpotomy, where the surface 1–2 mm of
exposed pulp tissue is removed by a slow bur, is also used
with equal success.
files and placement of MTA or biodentine at the fracture
line aims to produce a stop at the coronal side of the fracture line. The coronal portion can then be obturated with
gutta-percha and sealer.
If the apical portion is non-vital, it may be possible to
instrument across the fracture line, although it can be very
difficult to prevent bleeding into the canal. Failure to instrument a non-vital apical fragment necessitates surgical removal of the fragment. Splinting across fracture lines with
D
Root formation
is complete
calcific
barrier
A C
JM, Nunn JH. In: Welbury RR, ed. Paediatric Dentistry. 2nd edn. Oxford University
Press; 2001: 178, Fig. 9.18, By permission of Oxford University Press, www.oup.
com.)
B
D
Box 7.13 Permanent Root-End Closure
1. Use local anaesthesia.
2. Place rubber dam.
3. Access cavity (see Fig. 7.3A).
4. Extirpate necrotic pulp tissue.
5. Prepare canal 1 mm short of radiographic apex.
6. Gentle instrumentation and irrigation with 1% sodium
hypochlorite solution to remove and dissolve organic debris
and kill micro-organisms. Use gentle debridement in a crown–
apex direction and determine working length (see Fig. 7.3B).
7. Fill canal with calcium hydroxide as inter-visit medication if
required.
8. Place 5–6 mm of MTA (7.3C) at apex using specialised carriers
and pluggers, take check of periapical. Allow to set (time required dependent on the material used), then obturate canal
with gutta-percha, and restore tooth with composite.
9. If MTA placement not possible, can redress with non-setting
calcium hydroxide after 1–2 weeks, then 3 monthly (see
Fig. 7.3C). Via this method, the average time to barrier
formation is 1 year.
Master Dentistry
a post is a radical temporary solution with a poor long-term
prognosis.
Root Resorption of Permanent Teeth
Infection related: Infection-related resorption can affect the
external or internal root surface.
External. Resorption is initiated by damage to the peri-
odontal ligament, and then propagated by necrotic pulp
tissue via dentinal tubules. Diagnosis is by asymmetrical
radiolucent shape of surface of root with intact root canal walls (Fig. 7.4).
Internal. Resorption is initiated by cells of the pulp within
the root canal. Diagnosis is as a ballooning of the root
canal with intact root surface (Fig. 7.5).
Treatment of both types is by thorough mechanical and
chemical debridement, followed by non-setting calcium
hydroxide paste for 4 weeks. Obturation is then completed, although if resorption continues, the tooth will
eventually be lost.
Cervical. This is an unusual form of external infection-
related resorption initiated by damage to the root surface
in the cervical region and propagated either by infected
root canal contents or by periodontal microflora. Treatment is usually by obturation of the root canal, followed
by surgical external repair and restoration.
Ankylosis-related resorption (replacement resorption):
Ankylosis-related resorption is progressive resorption of
tooth structure and its replacement with bone as part of
continued bone remodelling. It occurs after trauma in
which there is significant periodontal ligament injury
(i.e. luxation, intrusion and avulsion). It cannot be
(From Whitworth JM, Nunn JH. In: Welbury RR, ed. Paediatric Dentistry.
Oxford University Press; 1997. By permission of Oxford University Press,
www.oup.com.)
treated. The tooth should be maintained in the mouth
for as long as possible which will avoid early need for
prosthetic tooth replacement and maintain adjacent
bone. Patients should be informed that Ankylosis-related
resorption will continue and the tooth will eventually be
lost. Consideration should be given to tooth removal or
decoronation when infra-occlusion is noted.
7.8. Molar-Incisor Hypomineralisation
resorption.
MIH is defined as a developmentally derived dental defect
that involves hypomineralisation of between 1 and 4 FPMs,
frequently associated with similarly affected permanent incisors.
Second primary molars, which form at a similar time as
the FPMs, can also be affected. This is defined as hypomineralised second primary molar (HSPM). It has been suggested
that the presence of hypomineralised second primary molars can be an early predicator of MIH, given these children
are 4.6 times more likely to have MIH (Garot et al 2018).
Teeth affected with MIH present with well-demarcated
areas of enamel hypomineralisation, which can vary in
size, position and colour. White opacities represent a milder
form, while yellow/brown lesions have more extensive hypomineralisation. The affected teeth initially erupt with a
normal thickness of enamel; however, hypomineralised
areas, particularly yellow/brown lesions affecting the posterior dentition, can be subject to rapid deterioration following eruption known as post-eruptive breakdown (PEB). This
leads to irregular cavitation and increases susceptibility to
plaque accumulation and dental caries. In more severely
affected teeth, it can lead to destruction of the crown
shortly after eruption.
Teeth affected by MIH can be acutely sensitive and uncomfortable when performing toothbrushing or consuming
cold or sweet food/drink.