What Is the Objective of Pediatric Dentistry?
Dental caries remains a significant global health issue, with a high prevalence even in the year 2021, particularly affecting children and young adolescents worldwide. Several factors contribute to this problem, including inadequate dental education and awareness, limited access to dental care, financial constraints, and dental fear, leading to delayed treatment until cavities are in an advanced stage or infected with pulpal involvement. The primary objective of dentists, especially in pediatric dentistry, is to promote tooth and supporting tissue health, preserving vital functions like mastication, speech, and aesthetics, all crucial for a child's psychosocial development. Additionally, pediatric dentists strive to maintain proper arch length and support healthy jaw growth patterns.
In pediatric dentistry, one conservative clinical procedure commonly used is the pulpotomy, which differs from the pulpectomy, and root canal treatment performed in adults. A pulpotomy involves removing only the coronal pulp tissue (pulp within the tooth crown region) while preserving the radicular pulp (pulp within the tooth root). The rationale behind this approach is to retain the healing ability of the remaining pulp tissue in the tooth, which can be beneficial in maintaining the overall health of the affected tooth.
What Is Pulpotomy?
A pulpotomy is a dental procedure that involves the removal of the pulp from the crown (main part) of a tooth while leaving the roots intact. To understand this procedure better, it is essential to know what tooth pulp is. The tooth pulp is a collection of soft tissues inside the tooth, including blood vessels, nerves, and connective tissue. These components are responsible for nourishing the tooth and transmitting sensory signals, such as pain, to the brain.
When a tooth experiences minor cavities on its surface, the pulp is not exposed, and prompt treatment of these cavities reduces the risk of damage to the pulp. However, in cases of more severe decay, the pulp may become exposed, allowing bacteria to infect it. Once the pulp is infected and dies, the infection can spread to the tooth's roots, requiring either a root canal treatment or tooth extraction to resolve the issue.
A pulpotomy is considered a less invasive alternative to a root canal or extraction. During the procedure, the affected pulp in the crown of the tooth is removed, but the roots are preserved. To protect the remaining roots, a medicated filling is typically placed. In some cases, a full crown may be added to provide maximum protection to the treated tooth.
Pulpotomies are commonly performed on children who have severe decay in their baby teeth. However, they may also be considered for adults, although historically, the procedure has not been very long-lasting, and it may be more challenging to perform on older adults due to changes in their teeth.
What Are the Factors Influencing the Success of Procedures and Indications?
Pulpotomy has long been the most popular and indicated vital pulp procedure in the field of pediatric dentistry. The pulpotomy procedure is a common treatment for children with significant cavitation or tooth decay that affects the pulp, especially in primary molars with extensive caries. However, its success is highly dependent on the dental operator's expertise and technique sensitivity. Various factors influence the outcome of a pulpotomy, including:
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Accurate assessment and diagnosis of the caries extent in the child's tooth.
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Proper and precise caries excavation methods during the procedure.
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Careful selection of appropriate pulp dressing material.
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The quality of the final restoration in the affected tooth.
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The experience and skill level of the dental operator performing the pulpotomy.
Therefore, the primary goal of the pediatric dentist is to achieve adequate hemostasis after amputating the affected or infected coronal pulp. The exposed pulp stumps are then covered with a pulp-capping agent that promotes healing. This procedure proves beneficial, especially when a primary tooth with deep cavitation shows no clinical symptoms of pain or swelling, indicating asymptomatic conditions. The main indications for pulpotomy are as follows:
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Primary asymptomatic teeth with extensive caries.
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Teeth showing no spontaneous pain during dental check-ups despite deep cavitation.
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No evidence of radicular pathologies in the affected tooth.
Considering current restorative trends in dentistry, the glass ionomer serves as the interim temporary restoration, typically placed for one to three months before vital pulp therapy (VPT), also known as the subsequent VPT filling. This approach not only enhances the clinical accuracy of diagnosing the pulp's clinical status but also contributes to the success of the subsequent VPT procedure.
What Are the Different Pulpotomy Agents?
Pulpotomy agents have certainly evolved over the last century with the advent of dentistry.
the action of pulpotomy agents range based on their following effects on the tooth pulp :
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Devitalization or mummification aims to preserve the radicular pulp.
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Minimal devitalization or non-inductive form of tissue regeneration by initiating reparative or inductive mechanisms of pulp healing.
The most popular materials or pulpotomy agents that have been used over time and are even currently in trend for this procedure with acceptable results are:
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Formocresol (FC).
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Ferric sulfate (FS).
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Sodium hypochlorite (SH).
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Calcium hydroxide (CH).
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Mineral trioxide aggregate (MTA), BiodentineTM, and bioceramic pastes (calcium silicate-based biomaterials).
What Are the Steps or Management of Children in Clinic?
As previously mentioned, Formocresol, Ferric Sulphate, and Sodium Hypochlorite are commonly used pulpotomy agents to achieve effective hemostasis during the pulpotomy procedure in children. However, there are non-pharmacological approaches as well, such as applying pressure with sterile cotton pellets directly onto the pulp chambers. These pellets can be used dry or lightly moistened with saline solution to attain hemostasis.
The routine pulpotomy procedure involves the following steps:
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Complete removal of caries.
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Opening of the pulp chamber.
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Ensuring adequate isolation.
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Obtaining an ideal coronal seal for the final restoration.
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Placing an intra-coronal stainless-steel crown (SSC) to achieve a good marginal seal for the affected tooth.
Stainless steel crowns (SSCs) are preferred by most pediatric dentists as the treatment of choice. The success of pulp therapy and the eruption of permanent teeth in the arch are influenced by the quality of the final restoration placed by the dentist.
The main challenge faced by pediatric dentists is, selecting the appropriate restorative material. In a pediatric dental setting, this decision is often influenced by patient cooperation. Younger children may be uncooperative or reluctant to interact correctly with the dentist compared to older children. As a result, frequently used temporary restorative materials like zinc-oxide-eugenol cement (IRM), glass-ionomer cement (GIC), resin-modified glass-ionomer cement (RMGIC), or compomers are used until the permanent teeth erupt.
Conclusion
To conclude, the success of the pulpotomy procedure lies in the operator's sensitivity, and the cooperation of the child and also relies highly on parents spreading dental or oral health awareness to their children. Frequently restoring the primary teeth is indeed a challenging task for the dentist, but it cannot be ignored either by the parents or the dentist owing to the risk of pulpal infections impacting the permanent teeth as well. Hence pulpotomy may be an essential requirement in extensively decayed teeth that are asymptomatic.
