The process of taking the pulp of milk teeth in children

In children, root canal treatment is more complicated because of the presence of two sets of teeth: baby teeth and permanent teeth. The pulp of a primary tooth differs from the pulp of a permanent tooth in growth, morphology, and histology. There are a number of techniques and medications that work well for permanent teeth but are bad for baby teeth (or vice versa). Therefore, the diagnostic process and the procedure for taking the pulp of baby teeth are also very different from those of permanent teeth.

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• 1. Diagnose the condition
• 2. Root canal treatments in baby teeth

1. Diagnose the condition

The pulp of a baby tooth can be affected in several ways:

• Cavities that progress through the enamel and dentin can cause pulp reactions such as acute or chronic pulpitis.
• Marrow degeneration.
• Trauma and over-preparation also lead to a marrow reaction.

In these cases, accurate diagnosis and treatment is required to eliminate pain and stimulate pulp healing so that the child's teeth can be kept healthy until the tooth is replaced.

Before treating the root canal of baby teeth, the doctor will carefully evaluate the medical history of the child and parents, perform a physical examination, and examine the correct X-ray film.

In addition, there are a number of other factors to consider, such as:

• Overall health status.
• Oral health status: with or without teeth that have just been lost or are likely to be lost and need to plan to keep space.
• The family's ability to assess and provide follow-up care.
• The regenerative capacity of teeth with pulp disease.
• Parents' motivation for tooth retention and financial viability.

Many primary teeth can be saved with appropriate root canal treatment. Extraction may be correct and necessary in some cases. However, extraction should not be done just because it is a simple measure, especially if tooth loss is causing a lack of space. Successful root canal treatment and good crown reconstruction will be the best space-saving appliance for children. Refer to the article: Premolars: A replacement tooth for baby molars 

Attention should be paid to the oral health of children.

1.1. Medical history

The doctor will determine whether the child has or does not have a painful tooth. Because sometimes children complain of toothache, but due to problems with teething and tooth replacement. During the examination, two main types of pain should be distinguished:

• Provocative pain: provoked by heat, cold, sour, sweet, vapor, chewing or other stimulus... ; causes pain but decreases or disappears when the stimulus ceases. It is dentin hypersensitivity in carious lesions or open fillings. There is little danger to the pulp and is reversible.
• Spontaneous pain: constant pain, can make the child unable to sleep, taking painkillers or sedation does not reduce. This type of pain indicates a progressive (irreversible) pulp injury. In addition, a history of swelling and redness (especially superficial swelling) requires special attention; especially when accompanied by fever or signs of systemic infection.

In children with new maxillofacial trauma, with painful baby teeth, attention should be paid to tooth fractures, displacement, and protrusion. Other children may arrive later after trauma with a dark front tooth without pain or discomfort. It is necessary to assess the pulp injury and the need for treatment. In addition to the history of major discomfort, the physician also focuses on the oral and medical history. If the child has severe systemic illness, appropriate treatment is required.

See also:  Pulp: Special tissue of tooth structure

Dental pulp is easily affected by tooth decay leading to infection.

1.2. Clinical examination

Intraoral examination of soft tissue to look for: swelling, redness, or fistula. Large caries and traumatized teeth are obvious manifestations of trauma, inflammation, and infection. However, clinical examination is sometimes difficult to see lateral ridge fractures, teeth with broken or missing fillings, teeth with previous root canal treatment...

1.2.1. Clinical diagnosis

Effective diagnostic methods in primary teeth include: assessment of wobble and sensitivity to percussion . Compare the swing of the suspected tooth with the teeth on the opposite arch. Significant differences indicate abnormalities of the teeth. Light tapping with fingertips (not a mirror handle) can help determine if the tooth is inflamed and the periodontal cord is affected.

1.2.2. X-ray examination

The doctor will give your baby an X-ray film to aid in diagnosis and treatment. An X-ray film of the opposite side may be attached for comparison.

X-ray films will help your doctor evaluate:

• Spread of caries and correlation to pulp.
• Previous root canal treatment and reconstruction: fillings close to the pulp horn or having undergone root canal treatment.
• Signs of pulp degeneration such as calcification or internal resorption.
• Periodontal space (normal and uniform or not) and lamina dura (intact or interrupted).
• Leg resorption is more consistent with a physiological response than a pathological response (compare left and right sides).
• Periapical radiolucency: In primary molars, the effect is often seen in the area covering the root of the tooth because the accessory canals in the chamber floor escape. the cleft is easier than through the apical foramen.

X-rays of the jaw help the doctor accurately diagnose the condition of the teeth.

Reading X-rays in children is quite complicated because of the presence of developing permanent teeth.

1.3. Live marrow assessment

Once a diagnosis is made, the doctor will begin treatment. During treatment, your doctor will use your senses of sight, touch, and smell. These are important factors in assessing the state of the existing pulp.

2. Root canal treatments in baby teeth

2.1. Indirect pulp cover

Indications: In teeth with carious lesions close to the pulp but no signs of pulp degeneration.

Purpose: Keep the spinal cord, prevent the progression of tooth decay. Stimulate dentin fibrosis, forming reactive dentin. Deep dentin remineralization.

Skill:

• Place a thin layer of drug over healthy dentin or deep dentin without clinically exposed pulp.
• Place calcium hydroxide [Ca(OH)2] for 6-8 weeks, then open up the remaining deep dentin and regenerate. Temporary reconstruction must be completely sealed.

Success rate: 90% in baby teeth

2.2. Cover the pulp directly

Indications: Mechanical or traumatic small pulp exposure in primary or permanent teeth; provide an optimal opportunity for a good pulp protective response.

Contraindicated in the following cases:

• Root canal exposure due to caries in milk teeth.
• Persistent inflammation.
• Internal consumption.
• Calcification.

Purpose: Keep the spinal cord, no symptoms after treatment, heal the pulp and create secondary dentin. In direct pulp capping, Ca(OH)2 is placed directly on the exposed pulp for stimulation.

See also: What is tooth decay? Causes, treatment and prevention

Cover the pulp directly with calcium hydroxide.

2.3. Take the pulp chamber in the milk teeth

Indications : Resection of infected pulpal tissue, preserving spinal cord tissue (or infected but alive), as determined by clinical and radiographic findings.

Purpose: Keeping custom legs alive; no signs or symptoms of persistent adverse effects; no internal resorption or calcification of the canal; Keeps supporting tissue healthy, does not harm the replacement tooth.

2.3.1. Clinical indications:

• Pulp exposure due to caries or mechanics.
• Inflammation limited to the pulp chamber.
• There is no spontaneous pain.
• There was no swelling or alveolar abscess.

2.3.2. Clinical and X-ray contraindications

• Spontaneous pain.
• Fistula or swelling.
• Necrotic marrow.
• Uncontrollable marrow bleeding..
• Radical periapical or tight zone.
• Pathological foot loss.
• Calcification.
• Consume more than 1/3 of the tooth root.

2.3.3. Drugs in chamber marrow technique

• Fixing agent

+ Formocresol: 19% formaldehyde, 35% cresol in a transport solution of 15% glycerin and water.

+ Glutaraldehyde (3 - 6%).

• Mineralizing/Alkaline Agent

+ Ca(OH)2.

+ Tricalcium phosphate.

• Ointment/pain reliever: Zinc Oxide and eugenol (ZOE).
• Astringent:

+ Epinephrine.

+ Iron sulfate.

+ Aluminum chloride.

• Antibiotics: Erythromycin. Vancomycin. Tetracyclines.
• Tissue healing agent: Collagen rich solution. Bone shaping factor.
• Glucocorticoids:

Success rate of pulpectomy (X-ray) : 62 – 97% depending on the study

The procedure for taking the pulp chamber.

2.3.4. The technique of taking marrow chambers

Root canal collection with formocresol is performed in the following sequence:

• Step 1: Open the entrance and get all the deep tusks

Local anesthesia, embankment, removal of deep dentin. Open the access to the pulp chamber sufficiently wide by connecting the pulp horns and completely removing the pulp chamber ceiling.

• Step 2: Root canal removal

Using a large sterile scraper, cut and remove all pulp tissue in the pulp chamber. Be careful not to pull the root pulp tissue or use a large circular drill, being careful not to puncture the pulp floor.

• Step 3: Stop the bleeding

Place a sterile cotton ball over the root opening and press firmly for a few minutes. When the cotton is removed, the bleeding should stop completely. If the blood is dark purple or bleeds heavily despite compressing the cotton ball, then the inflammation has spread to the pulp of the leg. Then the treatment must be changed (root root or tooth extraction). It should be noted that no direct anesthetic is applied to the pulp or no other hemostatic agent is used to stop the bleeding because bleeding is the criterion for assessing the condition of the pulp.

• Step 4: Place formocresol

Place a cotton ball impregnated with formocresol 1/5 on the root canal tip for 5 minutes. When removed, the tip of the tube is dark brown or black. Formocresol according to Buckley's formula: + Tricresol 35% + Formaldehyde 19% + Glycerin + Water 15% to 100%.

• Step 5: Put the eugenate, the regeneration is finished

Mix the thick eugenate on the floor of the pulp chamber, then mix the thicker and lighter eugenate to completely fill the pulp chamber. Final regeneration with a hunting crown. If possible, place immediately after root canal treatment. If this is not possible, use eugenate as a temporary filling while waiting for the crown to be placed.

2.4. Whole marrow extraction (Lower root canal)

Indications: For teeth with symptoms of chronic pulp inflammation or pulp necrosis.

Contraindications:

Teeth that have lost a lot of crown structure, have internal or external resorption or a periapical infection affecting the replacement tooth germ. In some cases, we can try to keep a primary tooth by taking a total root canal both when the condition is known and the prognosis is not ideal.

Example: When the second primary molar is deeply decayed before the first permanent molar erupts (about 6 years of age). If the 2nd molar is extracted without a space retainer, the 6th molar will grow proximally. The result is the loss of space for the permanent second premolar. Although distal spacers can be performed; But 1 baby tooth that is retained will be the best space retainer. Therefore, it is necessary to take root pulp for the second primary molar to keep until the sixth tooth erupts, then extract it and place a space retainer.

Image depicting the procedure of root canal extraction.

2.4.1. The technique of root canal extraction is performed as follows:

• Root canal access: same as in root canal therapy.
• Removal of pulp debris: scrape the pulp chamber with a scraper or circular drill. Use a needle of appropriate size to remove all pulp debris in the canal 2mm from the apex.
• Root canal preparation : use a file to prepare 2mm apex (check X-ray film). Very narrow canals in primary molars must be widened to 25-30 for a good filling. Avoid filing too wide because the root canal wall of primary teeth is thinner than in permanent teeth, so it is easy to perforate.
• Irrigate the canal during drilling to remove pulp debris. Irrigate with sodium hypochloride solution because it helps to dissolve organic matter. Care must be taken not to inject too much pressure into the periapical tissue or through the accessory canal into the cleft area. May be used alternately with sterile saline solution. Dry the canal with a paper port. The root canal can be filled immediately. Removal of all necrotic material and cleaning of the canal will promote healing and resolution of the infected area.

2.4.2. Filled with eugenate

For large canals such as in primary incisors, a layer of liquid mixture may be applied to the canal wall. Then, use a small amalgam stuffing stick to stuff a thick layer into the canal lumen, being careful not to overfill the hole outside the canal. For canals that are too small to be filled, a syringe is used and liquid eugenate is injected into the canal, taking care not to overdo it. If the root canal is filled with KRI, Maisto or Endoflas, use a lentulo attached to the elbow handpiece that rotates the medication. When the canal is full, press down with a cotton ball. Excess material will dissipate.

Fill the pulp chamber with solid beaten eugenate or reinforced oxide kem + eugenol.

2.4.3. Reconstruction with ready-made crowns

If in incisors, reconstructed with composite, the eugenate must be replaced with zinc phosphate or GIC.

Root canal treatment is a relatively lengthy and manipulative procedure. Especially for children, root canal treatment is relatively more difficult due to the high cooperation of children. Therefore, parents need to prepare the child's psychology before doing so to ensure the safety and cooperation of the child in treatment.

Doctor Truong My Linh