Management Of Deep Management Of Deep Carious Lesions In Carious Lesions In

ChildrenChildren

Presented byPresented byProf. Dr. Nevine WalyProf. Dr. Nevine Waly

Prof. in Pediatric Dentistry and Prof. in Pediatric Dentistry and Public Health Department Public Health Department Faculty of Oral and Dental Faculty of Oral and Dental

MedicineMedicineCairo University Cairo University

Pulp exposure is caused most Pulp exposure is caused most commonly by caries but may also occur commonly by caries but may also occur during cavity preparation or by fracture of during cavity preparation or by fracture of the crown. Pulp exposures caused by caries the crown. Pulp exposures caused by caries occur more frequently in primary than in occur more frequently in primary than in permanent teeth because primary teeth permanent teeth because primary teeth have relatively large pulp chambers, more have relatively large pulp chambers, more prominent pulp horns and thinner enamel prominent pulp horns and thinner enamel and dentine. In primary molars with proximal and dentine. In primary molars with proximal cavities, pulp involvement occurs in about cavities, pulp involvement occurs in about 85% of those with broken marginal ridges.85% of those with broken marginal ridges.

Diagnostic aids in selection Diagnostic aids in selection of teeth for vital pulp of teeth for vital pulp therapytherapy::1-1-History of painHistory of pain::

• The dentist should distinguish between two types of The dentist should distinguish between two types of pain: provoked and spontaneous pain (unprovoked).pain: provoked and spontaneous pain (unprovoked).

Provoked pain: Provoked pain: is precipitated by stimulus (thermal, is precipitated by stimulus (thermal, chemical or mechanical) and disappears after removal chemical or mechanical) and disappears after removal of stimulus:of stimulus:

• Pain associated with eating is due to pressure from Pain associated with eating is due to pressure from accumulated food within the carious lesion and accumulated food within the carious lesion and chemical irritation to the vital pulp protected by a thin chemical irritation to the vital pulp protected by a thin layer of dentine (good prognosis).layer of dentine (good prognosis).

• Pain due to cold food or drinks indicates hyperaemia.Pain due to cold food or drinks indicates hyperaemia.• Pain due to hot food or drinks indicates pulpitis.Pain due to hot food or drinks indicates pulpitis.Spontaneous pain: Spontaneous pain: is a throbbing constant pain that is a throbbing constant pain that

may keep the patient awake at night. It indicates may keep the patient awake at night. It indicates advanced pulp damage (poor prognosis).advanced pulp damage (poor prognosis).

22--Clinical signs and Clinical signs and symptomssymptoms::

• Abnormal tooth mobility indicates Abnormal tooth mobility indicates severely diseased pulp or involvement of severely diseased pulp or involvement of periodontal ligament.periodontal ligament.

• Sensitivity to percussion indicates apical Sensitivity to percussion indicates apical or periodontal inflammation or both.or periodontal inflammation or both.

• Presence of swelling, sinus, draining Presence of swelling, sinus, draining fistula or chronic abcess indicates a non fistula or chronic abcess indicates a non vital pulp.vital pulp.

• Size of exposure and amount of pulpal Size of exposure and amount of pulpal bleeding are the most valuable observations bleeding are the most valuable observations in diagnosing the condition of the primary in diagnosing the condition of the primary pulp:pulp:

– Small pin-point exposure surrounded by sound Small pin-point exposure surrounded by sound dentine indicates favorable pulp condition.dentine indicates favorable pulp condition.

– Large exposure with watery exudate or pus Large exposure with watery exudate or pus indicates unfavorable pulp condition.indicates unfavorable pulp condition.

– Small controllable amount of bleeding during and Small controllable amount of bleeding during and or following pulp amputation is a favorable or following pulp amputation is a favorable condition for pulp therapy.condition for pulp therapy.

– Excessive uncontrollable bleeding during and or Excessive uncontrollable bleeding during and or following pulp amputation is an unfavorable following pulp amputation is an unfavorable condition for pulp therapy.condition for pulp therapy.

33--Radiographic Radiographic interpretationinterpretation::

• Radiographic interpretation in children Radiographic interpretation in children is more difficult than adults due to:is more difficult than adults due to:– Young permanent teeth with incompletely Young permanent teeth with incompletely

formed root ends give the impression of formed root ends give the impression of Periapical radiolucency.Periapical radiolucency.

– The roots of primary molars undergoing The roots of primary molars undergoing normal physiologic resorption may suggest normal physiologic resorption may suggest a pathologic change.a pathologic change.

– Permanent teeth are superimposed on the Permanent teeth are superimposed on the primary teeth.primary teeth.

Radiographs are valuable Radiographs are valuable for determining the for determining the followingfollowing::

• Periapical changes such as widening Periapical changes such as widening of periodontal membrane space.of periodontal membrane space.

• Rarefaction in supporting bone.Rarefaction in supporting bone.

• Calcified masses within pulp Calcified masses within pulp chamber and root canals.chamber and root canals.

• Periapical and interradicular Periapical and interradicular radiolucencies of bone.radiolucencies of bone.

44--Vitality testsVitality tests : :Either thermal or electrical.Either thermal or electrical.

Thermal pulp vitality testsThermal pulp vitality tests::• Application of heat (hot gutta percha or hot Application of heat (hot gutta percha or hot

instrument).instrument).• Application of cold (ethyl chloride or ice cone).Application of cold (ethyl chloride or ice cone).• The reaction of a normal tooth is tested first The reaction of a normal tooth is tested first

(pain disappears after removal of stimulus).(pain disappears after removal of stimulus).• If pain persists, this indicates pulpitis.If pain persists, this indicates pulpitis.• If tooth does not respond, this indicates a non-If tooth does not respond, this indicates a non-

vital pulp.vital pulp.

Electric pulp testerElectric pulp tester::

• Record the reading of a normal tooth first.Record the reading of a normal tooth first.

• If the affected tooth responds at a lower If the affected tooth responds at a lower reading, this indicates hyperemia or pulpitis.reading, this indicates hyperemia or pulpitis.

• If the affected tooth responds at a higher If the affected tooth responds at a higher reading, this indicates pulp degeneration.reading, this indicates pulp degeneration.

Disadvantages of electric pulp testerDisadvantages of electric pulp tester::

• Child may become apprehensive and gives Child may become apprehensive and gives false response.false response.

• Gives false positive response when content Gives false positive response when content of pulp is liquid (liquifaction necrosis).of pulp is liquid (liquifaction necrosis).

55--Physical condition of Physical condition of patientpatient::

Seriously ill children e.g. heart disease, Seriously ill children e.g. heart disease, nephritis, leukemia or tumors should not be nephritis, leukemia or tumors should not be subjected to the possibility of an acute subjected to the possibility of an acute infection resulting from pulp therapy. infection resulting from pulp therapy. Moreover, the pulp might not posses normal Moreover, the pulp might not posses normal regenerative power. Extraction of the regenerative power. Extraction of the involved tooth after proper premedication involved tooth after proper premedication with antibiotics is the treatment of choice in with antibiotics is the treatment of choice in such conditions.such conditions.

Vital Pulp TherapyVital Pulp Therapy

Pulp CappingPulp Capping

The aim of pulp capping is to The aim of pulp capping is to maintain pulp vitality by placing a maintain pulp vitality by placing a suitable dressing either directly on suitable dressing either directly on the exposed pulp (direct pulp the exposed pulp (direct pulp capping) or on a thin residual layer of capping) or on a thin residual layer of soft dentine at the base of the cavity soft dentine at the base of the cavity (indirect pulp capping).(indirect pulp capping).

Indirect Pulp CappingIndirect Pulp Capping

DefinitionDefinition::• It is the procedure in which only the gross It is the procedure in which only the gross

caries is removed from the lesion, while the caries is removed from the lesion, while the remaining carious dentine which if removed remaining carious dentine which if removed would result in pulp exposure is covered would result in pulp exposure is covered with a material which promotes healing.with a material which promotes healing.

IndicationIndication::• Teeth with deep carious lesions Teeth with deep carious lesions

approximating the pulp, free of any clinical approximating the pulp, free of any clinical or radiographic signs of pulp disease.or radiographic signs of pulp disease.

TechniqueTechnique::

First visit:First visit:• Administer local anesthesia and isolate tooth Administer local anesthesia and isolate tooth

with rubber dam.with rubber dam.• Preoperative appearance of a deep lesion Preoperative appearance of a deep lesion

close to pulp in an asymptomatic vital tooth. close to pulp in an asymptomatic vital tooth. • Gross caries is excavated, while soft dentine Gross caries is excavated, while soft dentine

in the deepest portion is left and covered with in the deepest portion is left and covered with calcium hydroxide paste and a temporary calcium hydroxide paste and a temporary dressing. Tooth should not be re-entered for 6-dressing. Tooth should not be re-entered for 6-8 weeks. During that time the soft caries 8 weeks. During that time the soft caries becomes harder and calcium hydroxide will becomes harder and calcium hydroxide will stimulate the formation of secondary dentine stimulate the formation of secondary dentine and the remaining microorganisms will be and the remaining microorganisms will be destroyed by bactericidal action of calcium destroyed by bactericidal action of calcium hydroxide.hydroxide.

Second visitSecond visit::

• The tooth is reopened and remaining The tooth is reopened and remaining caries is carefully removed. Sound caries is carefully removed. Sound dentine is apparent which protects the dentine is apparent which protects the pulp. Apply calcium hydroxide dressing pulp. Apply calcium hydroxide dressing and restore the tooth. If a small and restore the tooth. If a small exposure is encountered a different exposure is encountered a different type of treatment is provided.type of treatment is provided.

Direct Pulp CappingDirect Pulp CappingDefinitionDefinition::• It is the procedure of covering the exposed It is the procedure of covering the exposed

ital pulp with a material which promotes ital pulp with a material which promotes healing.healing.

IndicationsIndications::• Small pinpoint exposure surrounded by Small pinpoint exposure surrounded by

sound dentine, produced accidentally during sound dentine, produced accidentally during cavity preparation or due to trauma.cavity preparation or due to trauma.

• Absence of pain with the exception of pain Absence of pain with the exception of pain during eating.during eating.

• Normal vital pulp.Normal vital pulp.• No bleeding at exposure site or an amount No bleeding at exposure site or an amount

that would be considered normal.that would be considered normal.• Normal radiographic findings.Normal radiographic findings.

TechniqueTechnique::• Administer local anesthesia and isolate tooth with Administer local anesthesia and isolate tooth with

rubber dam.rubber dam.• When pulp is exposed during the last stages of When pulp is exposed during the last stages of

caries removal, carious dentine chips will be pushed caries removal, carious dentine chips will be pushed into the pulp tissue which becomes contaminated into the pulp tissue which becomes contaminated resulting in pulpitis.resulting in pulpitis.

• So enlarging the exposure site is needed to wash So enlarging the exposure site is needed to wash away carious fragments and allow direct contact of away carious fragments and allow direct contact of capping material with pulp tissues.capping material with pulp tissues.

• Flush the cavity with noraml saline and dry the area.Flush the cavity with noraml saline and dry the area.• Cap the pulp with calcium hydroxide followed by Cap the pulp with calcium hydroxide followed by

zinc oxide eugenol then zinc phosphate cement and zinc oxide eugenol then zinc phosphate cement and the permanent restoration.the permanent restoration.

• N.B.N.B. Direct pulp capping is not encouraging in Direct pulp capping is not encouraging in primary teeth because pulp tissue ages early and primary teeth because pulp tissue ages early and less active undifferentiated mesenchymal cells are less active undifferentiated mesenchymal cells are available. Also, during Process of root resorption, available. Also, during Process of root resorption, cells may transform to odontoclasts causing internal cells may transform to odontoclasts causing internal resorption.resorption.

PulpotomyPulpotomy

Definition:Definition:• It is the removal of coronal pulp tissue till It is the removal of coronal pulp tissue till

the level of enterance of pulp canals and the level of enterance of pulp canals and capping the radicular pulp tissue to keep it capping the radicular pulp tissue to keep it in a good condition.in a good condition.

IndicationsIndications::• In primary and young permanent teeth In primary and young permanent teeth

with wide pulp exposures when the tissues with wide pulp exposures when the tissues adjacent to exposure site show slight adjacent to exposure site show slight evidence of inflammation.evidence of inflammation.

• Slight amount of bleeding at exposure site Slight amount of bleeding at exposure site which is considered within normal.which is considered within normal.

• Normal clinical and radiographic signs.Normal clinical and radiographic signs.

TypesTypes::• According to the capping material used:According to the capping material used: -Calcium hydroxide pulpotomy.-Calcium hydroxide pulpotomy. -Formocresol pulpotomy.-Formocresol pulpotomy.

Formocresol pulpotomyFormocresol pulpotomy::• There are two methods: -One visit technique.There are two methods: -One visit technique. -Two visits -Two visits

technique technique

One visit formocresol One visit formocresol pulpotomypulpotomy::

• Administer local Administer local anesthesia and isolate anesthesia and isolate tooth with rubber dam.tooth with rubber dam.

• Establish cavity outline Establish cavity outline and remove all caries and remove all caries before the pulp is before the pulp is exposed to prevent exposed to prevent bacterial contamination.bacterial contamination.

• Remove the roof of pulp Remove the roof of pulp chamber using a fissure chamber using a fissure bur.bur.

• Amputate coronal Amputate coronal pulp tissue till pulp tissue till enterance of root enterance of root canals with sharp canals with sharp spoon excavator spoon excavator or large round bur or large round bur at low speed.at low speed.

• Control bleeding with Control bleeding with cotton pellet moistened cotton pellet moistened with water placed over with water placed over amputated pulp stumps amputated pulp stumps for 3 minutes.for 3 minutes.

• When bleeding is When bleeding is arrested, apply a arrested, apply a cotton pellet moistened cotton pellet moistened with formocresol for 3-with formocresol for 3-5 minutes. Pulp stumps 5 minutes. Pulp stumps appear dark brown appear dark brown (fixed by formocresol).(fixed by formocresol).

• Cover radicular Cover radicular pulp stumps with pulp stumps with zinc oxide eugenol zinc oxide eugenol paste, fill pulp paste, fill pulp chamber with chamber with temporary cement temporary cement and prepare the and prepare the tooth for chrome tooth for chrome steel crown.steel crown.

• N.B.N.B. Success rates Success rates up to 98% have up to 98% have been reported been reported using pulpotomy using pulpotomy technique in vital technique in vital primary teeth.primary teeth.

Preoperative Preoperative PostoperativePostoperative

Two visits formocresol Two visits formocresol pulpotomypulpotomy::• If there is any sign of hyperemia following If there is any sign of hyperemia following

amputation of coronal pulp (pain or excessive amputation of coronal pulp (pain or excessive hemorrhage) indicating that inflammation is hemorrhage) indicating that inflammation is present in the tissues beyond the coronal present in the tissues beyond the coronal portion of the pulp , two visits formocresol portion of the pulp , two visits formocresol pulpotomy , partial pulpotomy or even pulpotomy , partial pulpotomy or even extraction of the tooth is indicated.extraction of the tooth is indicated.

• 1-After pulp amputation, a cotton pellet 1-After pulp amputation, a cotton pellet moistened with formocresol is placed over moistened with formocresol is placed over amputated pulp stumps and covered with amputated pulp stumps and covered with temporary dressing.temporary dressing.

• 2-In the second visit after 2-3 days isolate tooth 2-In the second visit after 2-3 days isolate tooth with rubber dam without local anesthesia, with rubber dam without local anesthesia, remove the dressing and pellet and complete remove the dressing and pellet and complete the procedure as one visit technique.the procedure as one visit technique.

Calcium hydroxide Calcium hydroxide pulpotomypulpotomy::

• It is indicated in young permanent teeth with It is indicated in young permanent teeth with exposed vital pulp and incomplete root exposed vital pulp and incomplete root formation.formation.

• After pulpotomy and formation of healthy clot , After pulpotomy and formation of healthy clot , a layer of calcium hydroxide is applied followed a layer of calcium hydroxide is applied followed by zinc phosphate cement then the permanent by zinc phosphate cement then the permanent restoration.restoration.

• Under calcium hydroxide, the pulp vitality is Under calcium hydroxide, the pulp vitality is maintained; it organizes an odontoblastic layer maintained; it organizes an odontoblastic layer to lay down reparative dentine and gives the to lay down reparative dentine and gives the chance for the root to complete its chance for the root to complete its development. This procedure gives 61% development. This procedure gives 61% success.success.

PulpectomyPulpectomyPartial pulpectomyPartial pulpectomy::DefinitionDefinition::• It is the removal of coronal pulp tissue and as much as It is the removal of coronal pulp tissue and as much as

possible of the contents of root canals without possible of the contents of root canals without interfering deeply into the apical portion.interfering deeply into the apical portion.

IndicationsIndications::• It is indicated in primary molars (due to difficulty of It is indicated in primary molars (due to difficulty of

performing complete pulpectomy because of difficulty performing complete pulpectomy because of difficulty to obtain adequate access to root canals in the small to obtain adequate access to root canals in the small mouth of children and due to the morphology of root mouth of children and due to the morphology of root canals such as lateral brancings and ramifications and canals such as lateral brancings and ramifications and presence of accessory root canals in primary molars presence of accessory root canals in primary molars where removal of all radicular pulp content is where removal of all radicular pulp content is impossible).impossible).

• When the coronal pulp tissue and the tissue When the coronal pulp tissue and the tissue entering the root canals are vital but show clinical entering the root canals are vital but show clinical evidence of hyperemia .evidence of hyperemia .

• The tooth may or may not have a history of pain.The tooth may or may not have a history of pain.• Normal radiographic findings.Normal radiographic findings.

Technique:Technique:

• Administer local anaesthesia and isolate Administer local anaesthesia and isolate tooth with rubber dam.tooth with rubber dam.

• Remove all caries and roof of pulp Remove all caries and roof of pulp chamber and amputate coronal pulp chamber and amputate coronal pulp tissue.tissue.

• Remove all accessible radicular pulp tissue Remove all accessible radicular pulp tissue with hedstrom files or barbed broaches.with hedstrom files or barbed broaches.

• File the canals to the resistance point. File the canals to the resistance point. Usually the file stops at curvature in Usually the file stops at curvature in apical 1/3 of root.apical 1/3 of root.

• Irrigate canals with normal saline and dry Irrigate canals with normal saline and dry with paper points.with paper points.

• Apply cotton pellet with formocresol for Apply cotton pellet with formocresol for 3 minutes to fix remaining pulp tissue.3 minutes to fix remaining pulp tissue.

• Coat the walls of canals with creamy zinc Coat the walls of canals with creamy zinc oxide eugenol paste using the last file or oxide eugenol paste using the last file or paper points.paper points.

• Fill canals with stiffer mix of zinc oxide Fill canals with stiffer mix of zinc oxide eugenol [ rolled into a point and eugenol [ rolled into a point and condensed with root canal plugger ].condensed with root canal plugger ].

• Fill pulp chamber with temporary cement Fill pulp chamber with temporary cement and prepare tooth for chrome steel and prepare tooth for chrome steel crown.crown.

Non-vital pulp therapyNon-vital pulp therapyComplete pulpectomy [endodontic Complete pulpectomy [endodontic

treatment ] Definition:treatment ] Definition:• It is the complete removal of coronal It is the complete removal of coronal

and radicular pulp tissue. and radicular pulp tissue. Indications:Indications:• In non-vital primary anterior teeth In non-vital primary anterior teeth

where the root canals are accessible. where the root canals are accessible. The canals may be cleaned and The canals may be cleaned and filled with a resorbable material such filled with a resorbable material such as zinc oxide eugenol , oxypara or as zinc oxide eugenol , oxypara or calcium hydroxide pastecalcium hydroxide paste

Treatment of non-vital Treatment of non-vital primary molarsprimary molars: :

Ideally a non-vital tooth Ideally a non-vital tooth should be treated by pulpectomy should be treated by pulpectomy and root canal filling. However, and root canal filling. However, pulpectomy in primary molars is pulpectomy in primary molars is extremely difficult and often not extremely difficult and often not practical. A non-vital pulpotomy practical. A non-vital pulpotomy method is advocated.method is advocated.

Technique of non-vital Technique of non-vital pulpotomypulpotomy::

First visit :First visit :• Necrotic coronal pulp tissue is removed . Necrotic coronal pulp tissue is removed . • Light instrumentation of canals to Light instrumentation of canals to

establish drainage.establish drainage.• Seal a cotton pellet with formocresol or Seal a cotton pellet with formocresol or

beech wood cresote or camphorated beech wood cresote or camphorated monochlorophenol into the pulp chamber monochlorophenol into the pulp chamber for 7-10 days. The strong antiseptic for 7-10 days. The strong antiseptic action of these materials combats action of these materials combats infection in radicular pulp. infection in radicular pulp.

Second visitSecond visit::• Remove cotton pellet and place Remove cotton pellet and place

antiseptic paste [ eugenol, formocresol antiseptic paste [ eugenol, formocresol and zinc oxide powder ] .and zinc oxide powder ] .

• Press antiseptic paste into root canals Press antiseptic paste into root canals with a cotton pellet. Pressure forces with a cotton pellet. Pressure forces the paste down the root canals .the paste down the root canals .

• Restore the tooth in usual manner. Restore the tooth in usual manner. • N.B: This technique could be used in N.B: This technique could be used in

the presnce of sinus , abcess or some the presnce of sinus , abcess or some degree of tooth mobility. A sinus is degree of tooth mobility. A sinus is expected to disappear following expected to disappear following control of infection and a mobile tooth control of infection and a mobile tooth becomes firm as periapical bone becomes firm as periapical bone reforms .reforms .

Commonly used capping Commonly used capping materialsmaterials::

Formocresol:Formocresol:• Buckleys formocresol which is composed of 19% Buckleys formocresol which is composed of 19%

formalin , 35% cresol and 15% glycerin and formalin , 35% cresol and 15% glycerin and distilled water . The reaction of formocresol is distilled water . The reaction of formocresol is progressive fixation of pulp tissue with ultimate progressive fixation of pulp tissue with ultimate fibrosis of the entire pulp.fibrosis of the entire pulp.

Calcium hydroxide:Calcium hydroxide:• Highly alkaline with pH 12 . One month after Highly alkaline with pH 12 . One month after

capping the pulp with calcium hydroxide , a capping the pulp with calcium hydroxide , a calcified bridge is formed and the pulp calcified bridge is formed and the pulp underneath this bridge remains vital thus allowing underneath this bridge remains vital thus allowing continued apical development in immature continued apical development in immature permanent teeth.permanent teeth.

• N.B. Electrosurgery and laser have been used N.B. Electrosurgery and laser have been used recently in pulpotomy procedure.recently in pulpotomy procedure.

Failures following vital Failures following vital pulp therapypulp therapy::

1-1-Internal resorption:Internal resorption:

• Occurs within pulp canals several Occurs within pulp canals several months following pulpotomy.months following pulpotomy.

• It is a destructive process due to It is a destructive process due to osteoclastic activity.osteoclastic activity.

• Pulp canals become widened, walls Pulp canals become widened, walls become thin and perforation may become thin and perforation may occur.occur.

Etiology:Etiology:• All capping materials are irritating All capping materials are irritating

and produce some inflammtion , and produce some inflammtion , inflammatory cells attract inflammatory cells attract osteoclasts which initiate internal osteoclasts which initiate internal resorption.resorption.

• Because the roots of primary are Because the roots of primary are undergoing normal physiological undergoing normal physiological resorption resorption

• there is osteoclastic activity in the there is osteoclastic activity in the area which predisposes the tooth to area which predisposes the tooth to internal resorption.internal resorption.

22--Alveolar abcessAlveolar abcess::

• Develops several months following Develops several months following pulp therapy.pulp therapy.

• Infection may be present in bone Infection may be present in bone around root apex or more around root apex or more commonly in bifurcation area.commonly in bifurcation area.

• May be associated with fistula in May be associated with fistula in chronic conditions.chronic conditions.

Pulp therapy for young permanent Pulp therapy for young permanent teethteeth

Apexogenesis [ vital pulpotomy ]Apexogenesis [ vital pulpotomy ]::Indications:Indications:• Vital permanent teeth with immature Vital permanent teeth with immature

root development having large root development having large carious or traumatic exposures.carious or traumatic exposures.

Aim:Aim:• Maintain the radicular pulp vital to Maintain the radicular pulp vital to

allow complete root development. allow complete root development. Calcium hydroxide placed over Calcium hydroxide placed over radicular pulp stumps stimulates the radicular pulp stumps stimulates the formation of a calcific bridge and formation of a calcific bridge and successful root closure.successful root closure.

Apexification [ root end Apexification [ root end closure in non-vital teeth ]closure in non-vital teeth ]::

Indications:Indications:• In young permanent teeth with pulp necrosis In young permanent teeth with pulp necrosis

and incompletely formed apices. and incompletely formed apices.Aim:Aim:• To promote root elongation and or calcific To promote root elongation and or calcific

root closure . Even though the pulp is root closure . Even though the pulp is necrotic , epithelial root sheath of Hertwig necrotic , epithelial root sheath of Hertwig persists and allows regeneration.persists and allows regeneration.

Technique:Technique:• The entire pulp s removed and calcium The entire pulp s removed and calcium

hydroxide is used to fill the root canals and hydroxide is used to fill the root canals and is replaced every 3-4 months until apical is replaced every 3-4 months until apical closure occurs . The tooth is then treated closure occurs . The tooth is then treated with root canal therapy.with root canal therapy.

Early Childhood CariesEarly Childhood Caries

• Definition:Definition:• A specific pattern of caries affecting the primary A specific pattern of caries affecting the primary

teeth of an infant during the first three years of age.teeth of an infant during the first three years of age.• EtiologyEtiology::• Wrong nursing habits (either breast or bottle feeding Wrong nursing habits (either breast or bottle feeding

during night or at bedtime).during night or at bedtime).• Regular use of a sweetened comforter (a bottle Regular use of a sweetened comforter (a bottle

containing sweet beverages at night, at bed time or containing sweet beverages at night, at bed time or during the day).during the day).

• Breast feeding beyond the normal age for weaning.Breast feeding beyond the normal age for weaning.• Falling asleep with pacifier covered with honey or Falling asleep with pacifier covered with honey or

jam.jam.• Regular use of syrups for therapeutic reasons in Regular use of syrups for therapeutic reasons in

chronic illness.chronic illness.

• MechanismMechanism::

• When the child falls asleep, the milk When the child falls asleep, the milk or sweetened liquid is pooled around or sweetened liquid is pooled around the maxillary anterior the maxillary anterior teeth.Acidogenic bacteria produce teeth.Acidogenic bacteria produce acids. Salivary flow is decreased acids. Salivary flow is decreased during sleep, so the clearance of the during sleep, so the clearance of the liquid from the oral cavity is slowed.liquid from the oral cavity is slowed.

Clinical pictureClinical picture::

• Clinical pictureClinical picture::

• 1-1-Teeth affectedTeeth affected::

• The four maxillary incisors are most The four maxillary incisors are most affected.affected.

• The four mandibular incisors usually The four mandibular incisors usually remain sound because the tongue lies remain sound because the tongue lies over the lower teeth during sucking.over the lower teeth during sucking.

• The other primary teeth may show caries The other primary teeth may show caries depending on how long the carious depending on how long the carious process remains active.process remains active.

22--Clinical patternClinical pattern::

• The maxillary incisors develop a The maxillary incisors develop a band of dull white demineralization band of dull white demineralization along the gum line that goes along the gum line that goes undetected by parents.undetected by parents.

• Then the white lesions develop into Then the white lesions develop into cavities that circle the necks of teeth cavities that circle the necks of teeth with a brown or black collar.with a brown or black collar.

• In advanced cases the crowns of the In advanced cases the crowns of the four maxillary incisors may be four maxillary incisors may be destroyed completely leaving destroyed completely leaving decayed brownish black root stumps.decayed brownish black root stumps.

ManagementManagementA-A-PreventionPrevention::• National educational programs for mothers to influence National educational programs for mothers to influence

their dietary habits as well as those of their infants.their dietary habits as well as those of their infants.• Water fluoridation.Water fluoridation.• Early dental examination at or before the age of one Early dental examination at or before the age of one

year.year.• Parents counseling: Parents counseling: • From birth, the infant should be held while feeding.From birth, the infant should be held while feeding.• The child who falls asleep while nursing should be The child who falls asleep while nursing should be

burped and then placed in bed.burped and then placed in bed.• The mother should wean the child as soon as he can The mother should wean the child as soon as he can

drink from a cup at approximately 12-15 months of drink from a cup at approximately 12-15 months of age.age.

• Avoid prolonged and frequent infant feeding habits.Avoid prolonged and frequent infant feeding habits.• Professional application of topical fluoride.Professional application of topical fluoride.• Development of appropriate dietary and oral hygiene Development of appropriate dietary and oral hygiene

habits at home.habits at home.

B-B-Treatment:Treatment:

• Cessation of habit.Cessation of habit.

• Sealing all caries free pits and Sealing all caries free pits and fissures.fissures.

• Fluoride application.Fluoride application.

• Gross excavation of carious lesions Gross excavation of carious lesions and filling cavities with re-enforced and filling cavities with re-enforced zinc oxide eugenol or glass ionomer zinc oxide eugenol or glass ionomer cement to arrest caries and prevent cement to arrest caries and prevent its progression to the pulp.its progression to the pulp.

• Pulp therapy and restoration of teeth.Pulp therapy and restoration of teeth.