Concise Guide to Pediatric Endodontics and Trauma

                                                                                                                                            AUTHOR: MICHAEL L. SOSNAY, DDS

Introduction

Guide description:

This guide presents an overview of all the possible endodontic procedures that your pediatric patients may require. The guide is divided into three sections.

  1. Primary teeth: from pulp liners to full root canal therapy
  2. Immature permanent teeth: from apexogenesis to apexification to full root canal therapy.
  3. Traumatic dental injuries and their management for both permanent and primary teeth. Including: crown fractures, root fractures, alveolar process fractures, concussions, subluxation, lateral luxation, Intrusion luxation, extrusion luxations, and avulsions.

Professional biography:

Michael L. Sosnay, DDS is an Endodontic specialist, practicing in New York City since 1999. He received his Doctorate of Dental Surgery in 1995 from New York University Dental School and was an NYU Dean’s Dental Merit Scholar. Dr. Sosnay holds a dual specialty degree in Endodontics and Pediatric Special Care dentistry.  Dr. Sosnay received his Post Doctoral Degree in Endodontics in 1999.  He also served as Director of Endodontics and Associate Clinical Professor at the Rose F. Kennedy Center – Jacobi Hospital/Albert Einstein.

Dr. Sosnay has widely lectured on Endodontic theory, diagnosis and treatment modalities, as well as Pediatric Endodontics & Trauma and has recently published a “Concise Guide to Pediatric Endodontics & Trauma.” He is a member of the American Dental Association, New York State Dental Association, New York County Dental Society, American Association of Endodontists and Special Care Dentistry Association

Disclaimer: These guidelines are intended to provide information to healthcare providers caring for patients with dental injuries. They represent the current best evidence based on literature and professional opinion. As is  true for all guidelines, the health care provider must apply clinical judgment dictated by the conditions present at the given traumatic situation. The IADT does not guarantee favorable outcomes from following the guidelines, but using the recommended procedures can maximize the chances of success.

Primary Teeth-Pulp Therapy

Objective: Preserve pulp tissue

Reason: Primary teeth with vital pulp tissue have a better prognosis and thus a better chance to exfoliate on time (avoiding space maintenance and orthodontic issues).

1. Problem: Deep caries

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Treatment: PROTECTIVE LINER; excavate decay, place a liner like caoh, dentin bonding agent, or glass ionomer, and cover with a permanent restoration.

2. Problem: Small carious pulpal exposure and no significant pain indicating pulpal degeneration.

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Treatment: INDIRECT PULP CAP; excavate the gross caries, however leave the caries directly over the pulp chamber to avoid pulpal exposure, cover with a biocompatible material like caoh or glass ionomer to stimulate healing, and that is covered with a permanent restoration.

3. Problem: Pinpoint pulpal exposure encountered during cavity preparation or traumatic injury, and no significant pain.

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Treatment: DIRECT PULP CAP: the pulp tissue is covered with a biocompatible base like caoh or mta and a permanent filling is placed on top.

4. Problem: Large carious pulpal exposure and no significant pain.

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Treatment: PULPOTOMY: pulp tissue in the pulp chamber is removed, the pulp chamber is dabbed with a wet cotton pellet of sodium hypochlorite, and once bleeding is controlled, the chamber is filled with; 1.buckleys solution (formocresol and ferric sulfate), 2.gluteraldehyde and caoh (less successful), or 3.mta (most successful), then a permanent restoration is placed on top for a proper seal and covered with a stainless steel crown (most effective long term).

5.Problem: Non-vital pulp tissue, furcal bone loss, or pain i.e. irreversible pulpitis pain.

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Treatment: PULPECTOMY; fill the canals with resorbable material like 1.kri (z.o.e and iodoform paste) or 2.vitapex (iodoform and caoh), that will resorb along with the roots, and then a permanent restoration is placed on top.

6. Problem: No permanent successor and the tooth has non-vital/necrotic pulp tissue or pain i.e. irreversible pulpitis pain.

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Treatment: conventional RCT with a nonresorbable root filling like gutta percha and sealer or Mta.


Note: space maintenance rule:

If the ‘e’ tooth or primary second molar is lost early, space maintenance is always necessary to allow the permanent successor i.e. premolar to erupt into place.

If the ‘d’ tooth, or primary first molar is lost early, then it depends. If the 6 year molar has already erupted fully, then space maintenance is not necessary, however if it has not erupted into place yet, then space maintenance will be necessary, for its eruption will drive the ‘e’ tooth mesially thus blocking out the premolar from erupting.

Immature Permanent Teeth

Objective: preserve pulp tissue.

Reason: vital pulp tissue is necessary to help the immature tooth complete its root development, which improves its long-term prognosis.

1. Problem: Deep caries with no pupal exposure and no significant pain.

s2_img1Treatment: PROTECTIVE LINER-excavate decay and place a thin protective liner like caoh, dentin bonding agent, or glass ionomer over the pulp chamber to protect the pulp, and then place a permanent restoration on top.

2. Problem: Small carious pupal exposure and no significant pain.

s2_img2Treatment: INDIRECT PULP CAP – excavate the gross caries, leaving a carious mass over the pulp to avoid pulp exposure, then place a protective liner like glass ionomer over the remaining caries, and cover with a permanent restoration. You can leave alone or re-enter the tooth 3-6 months later to excavate the remaining decay.

3. Problem: Pinpoint pulpal exposure encountered during decay excavation or traumatic injury and normal pulp tissue i.e. asymptomatic or reversible pulpitis

s2_img3Treatment:  DIRECT PULP CAP – the pulp tissue is covered with mta, which is covered with a wet cotton pellet (to allow the mta to set) and temporized. The patient returns to have the temp and cotton removed and a permanent filling is placed.

Note:  for small carious pulpal exposure the indirect pulp cap is the preferred method.

4. Problem: Large carious pulpal exposure and normal pulp tissue i.e. asymptomatic or reversible pulpitis

s2_img3Treatments:

  1. PARTIAL PULPOTOMY (CVEK) – remove 1-3mm of coronal pulp tissue (with a high speed diamond bur with coolant) beyond the caries to reach healthy pulp tissue, dab remaining pulp tissue with a sodium hypochlorite cotton pellet to control the bleeding, cover the remaining pulp tissue with mta, cover the mta with a wet cotton and temporary filling. The patient returns to have the temp and cotton removed, and a permanent restoration is placed.
  2. FULL PULPOTOMY – remove all pulp tissue from the chamber, control bleeding with sodium hypochlorite cotton pellet, fill the pulp chamber with mta and cover with wet cotton and temporize. The patient returns for the removal of the temp and cotton and a permanent restoration is placed.

Note: all 4 of the above problems can be considered apexogenesis, for they promote apical root development by aiming to preserve vital pulp tissue.

5. Problem: Apexified tooth i.e. closed apicies, with necrotic pulp tissue or irreversible pulpitis

s2_img4Treatment: CONVENTIONAL RCT

6. Problem: Incompletely developed tooth with open apicies, with necrotic pulp tissue or irreversible pulpitis 

s2_img5Treatment: UNCONVENTIONAL RCT – remove all the pulp tissue from the chamber and canals and fill them with caoh for 2-4 weeks to disinfect the canal space. Then bring the patient back to remove the caoh, place an mta apical seal and backfill with gutta percha.

Note: on a tooth with a wide-open apex ie. #8, you can place CollaCote (collagen) just past the apex, in order to have something firm to pack the mta up against, avoiding extrusion.

Traumatic Dental Injuries

I. Permanent Teeth

Key:

  1. Format: each condition has four components: problem i.e. diagnosis, treatment, prognosis, and patient instructions.
  2. ’Monitor’: means to follow the ‘follow up protocol’ listed at the end of this section under ‘charts’

1. Problem: Concussion: tooth is tender to touch

Treatment: MONITOR

Prognosis:  pulp complications are rare and root resorption is very rare.

Pt. instructions: soft food-1 wk., good oral hygiene, and chlorhexidine rinse-2weeks.

2. Problem: Subluxation-tooth is tender to touch and mobile (but not displaced)

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Treatment: Flexible splint (.016”-.4mm) for 2 weeks is optional, then MONITOR.

Prognosis:  pulp complications are rare and root resorption is very rare.

Pt. instructions: soft diet-1 wk., good O.H, chlorhexidine-2 wks.

3. Problem: Lateral luxation-tooth is displaced laterally and usually accompanied by an alveolar fracture

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Treatment: Rinse area with saline, REPOSITION the tooth with your fingers or a forcept: Pull the tooth coronally at first to free the tooth from its incorrect bony locked position, and then back apically into its proper position. Flexible splint for 2-4 weeks.
  • Open apex: can revascularize, so MONITOR. If pulp devitalizes-3 options: caoh traditional apexification, immediate RCT with mta seal of apex, or regenerative pulp therapy.
  • Closed apex: pulp necrosis is common, so conventional RCT can be initiated before splint removal or MONITOR..

Prognosis:

  • Open apex: guarded pulpal prognosis
  • Closed apex: poorer pulpal prognosis
  • Root resorption is rare.

Pt. instructions: soft diet-1 wk., good o.h, chlorhexidine-2 wks.

4. Problem:  Extrusion luxations-tooth appears elongated and is mobile.

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Treatment: rinse the area with saline, REPOSITION, and flexible splint for 2 weeks.
  • Open apex: can revascularize, so MONITOR .If pulp devitalizes-see the 3 treatment options listed in case #3.
  • Closed apex: pulp necrosis is common, so conventional RCT can be initiated right before splint removal, or MONITOR.

Prognosis:

  • Open apex: guarded pulpal prognosis
  • Closed apex: poorer pulpal prognosis
  • Root resorption is rare.

Pt. instructions: soft diet-1 wk., good o.h, chlorhexidine-2 wks.

5. Problem: Intrusion luxations – the tooth is pushed apically into the socket and accompanied by an alveolar fracture

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Treatment:  REPOSITION

OPEN APEX:

0-7mm intruded: allow 3 wks. to re-erupt. If it doesn’t, then initiate orthodontic repositioning.

7mm or more intruded: immediately reposition orthodontically or surgically

Revascularization is possible in both cases, so MONITOR.

CLOSED APEX:

0-3mm:allow 3 wks. To re-erupt, if not then reposition orthodontically or surgically. Then RCT (caoh 4 wks. prior to fill) for the pulp will likely necrose.

3-7mm:reposition orthodontically or surgically and flexible splint for 2 wks., then RCT.

7mm or more: reposition surgically and flexible splint 2-4 wks., then RCT.

Prognosis:

  • Open apex: guarded pulpal prognosis
  • Closed apex: poor pulpal prognosis
  • Root resorption: guarded prognosis, for infection and ankylosis related resorption are frequent findings.

Pt. instructions: soft diet-1 wk., good o.h, chlorhexidine-2 wks.

6. Problem: Infraction-Enamel crack

Treatment: etch and seal with resin to prevent discoloration, no need to monitor.

7. Problem: Uncomplicated crown fracture i.e. without pulp exposure and asymptomatic

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Treatment: 3 options: glass ionomer bandage, permanent composite BONDING, or can bond the fragment back if available. Follow up at 8 wks. and 1 year.

Prognosis: pulp complications and root resorption are rare.

Pt.instructions: soft diet-1 wk., good o.h, chlorhexidine-2 wks.

8. Problem: Complicated crown fracture i.e. with pulp exposure

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Treatment:
  • Open apex: MTA PULP CAP or MTA PARTIAL PULPOTOMY (cvek) and then restore (research shows very high success rates for both). Follow up at 8wks and 1 yr.
  • Closed apex: 3 options: MTA PULP CAP, MTA PULPOTOMY, or RCT. Then follow the ‘follow up protocol’ listed below.

Prognosis:

  • Open apex: remaining pulp tissue has a good prognosis
  • Closed apex: remaining pulp tissue has a good prognosis
  • Root resorption is rare.

9. Problem: Crown root fracture

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Treatment:  The primary goal is to create a situation where the tooth can be restored after fragment removal, so EXPOSE THE SUBGINGIVAL FRACTURE SITE by gingivectomy, surgical exposure, orthodontic extrusion or surgical extrusion.
  • Uncomplicated (no pulp exposure) – remove fragment and restore
  • Complicated (pulp exposure)
    • Open apex: perform MTA PULP CAP or MTA PULPOTOMY (apexogenesis) follow at 8wks and 1 yr.
    • Closed apex: perform RCT and restore with a post.

Prognosis:

  • Uncomplicated: Both pulp and root have a good prognosis
  • Complicated:
    • Open apices: remaining pulp tissue has a good prognosis    
    • Closed apices: the root has a good prognosis once RCT has been performed.
    • Root resorption is rare.

Pt. instructions: soft diet and soft brush

10. Problem: Horizontal root fracture and the coronal portion is usually mobile

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Treatment: REPOSITION the coronal fragment and stabilize with a flexible splint for 3-4 weeks and monitor, but if at the c.e.j-splint 4 months and monitor.

If RCT is indicated based on testing outcomes, cleaning and filling to the fracture site is the suggested Tx. method.

Prognosis:

  • Overall prognosis: further apical the fracture the better the prognosis
  • Pulpal prognosis: depends on two factors: tooth maturity and degree of luxation. The less mature and the less displacement, the better the chances of revascularization, so RCT would not be necessary.
  • Root resorption prognosis: healing resorption or remodeling is a common finding, and pathological resorption is rare.

Pt. Instructions: soft diet and soft brush

Biological considerations: The coronal portion can be considered a luxated tooth with damage to both the neurovascular supply and the PDL. While the apical portion remains relatively uninjured.

Three types of diastasis i.e. ‘fracture gap’ healing:

  1. Hard tissue: where new dentin from odontoblasts and new cementum from the invading periodonum bridge the ‘fracture gap’. (Seen mostly in immature teeth and mature teeth in young patients)
  2. Connective tissue: connective tissue fills the ‘fracture gap’, as a result of the invading PDL cells. (Seen on mature teeth)
  3. Granulation tissue: granulation tissue fills the ‘fracture gap’, as a result of a necrotic pulp complex. (Seen on necrotic teeth)

11. Problem: Alveolar fracture

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Treatment: REPOSITION the fragment and stabilize with a flexible splint for 3-4 weeks, and MONITOR. Pulpal necrosis is a frequent finding, so RCT will probably be indicated.

Prognosis:

  • Poor pulpal prognosis, for pulpal necrosis is a frequent finding.
  • Root resorption is rare.

Pt. Instructions: soft diet and soft brush.

12. Problem: Avulsed tooth with open apex, extraoral dry time less than one hour and stored in a storage media like saline, saliva, or milk the rest of the time

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Treatment: Clean root surface with saline, place in doxycycline solution (1mg/20ml saline), local anesthesia, remove coagulum from socket with saline, REPLANT the tooth with gentle pressure, apply a flexible SPLINT for 1-2 weeks, administer systemic antibiotics: For patients under 7 years old prescribe amoxicillin (dose by weight) and for patients 7 y.o. and older prescribe doxycycline (dose by weight),tetanus if tooth fell in dirt ,soft diet, rinse with .12% chlorhexidine 2x a day for 7 days, MONITOR for revascularization.

Prognosis:

  • Pulpal prognosis is guarded, for revascularization can occur, but if not RCT will be necessary.
  • Root resorption has a guarded prognosis as well, for it may occur.

Biological considerations: revascularization and reinnervation take place in the apical to coronal direction at a rate of .5 mm per day. Whether these processes are successful, depends upon the size of the apical foramen and the presence of bacteria. If the foramen is constricted and or bacteria are present in significant quantity, then the pulp tissue will necrose. If regeneration is successful, then new hard tissue will be deposited along the walls of the canal, leading to canal obliteration. In addition, cementoclasts are activated to remove apical bone, to make room for neurovascular reattachment, this will appear as a PAR at first, and then fill in with bone later on, so if a PAR appears on the radiograph at first and the tooth tests vital, don’t perform root canal treatment just yet, but rather monitor for bone regrowth.

13. Problem:  Avulsed tooth with closed apex, with extraoral dry time less than an hour and stored in a storage media the rest of the time.

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Treatment: Clean root surface with saline, local anesthetic, remove coagulum from the socket with saline, REPLANT the tooth with gentle pressure, apply a flexible SPLINT for 1-2 weeks, administer systemic antibiotics: under 7 y.o-amoxicillin for 7 days (dose by weight) and 7 and older-doxycycline for 7 days (dose by weight), initiate Rct 7 days after the avulsion-caoh intracanal medicament for 4 wks. then fill, tetanus if tooth fell in the dirt, then monitor.

Prognosis:

  • Pulpal prognosis is poor
  • Root resorption has a guarded prognosis, for it may occur.

14. Problem: Avulsed tooth with open apex with extra oral dry time more than one hour

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Treatment:  The A.A.E guidelines in the past called for extraction, but in 2013 they adopted the international organization of dental trauma guidelines:

Remove attached necrotic tissue with gauze, local anesthetic, perform RCT extraorally irrigate the socket with saline, REPLANT the tooth with gentle pressure, stabilize the tooth with a non-rigid splint for 4 weeks, administer systemic antibiotics i.e. amoxicillin or doxycycline, tetanus if tooth fell in dirt, monitor

Prognosis: Delayed replantation has a poor long-term prognosis. The PDL will be necrotic and not expected to heal. The expected outcome is ankylosis and root resorption. However, the goal of replantation is aesthetic, functional, psychological, and to maintain alveolar ridge contour.

15. Problem: Avulsed tooth with closed apex, with extra oral dry time more than one hour

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Treatment: remove attached necrotic tissue with gauze, immerse the tooth in 2% sodium fluoride for 20 minutes, local anesthetic, irrigate the socket with saline, extraoral RCT, REPLANT the tooth with gentle pressure, place flexible splint for 4 weeks, administer systemic antibiotics i.e., amoxicillin or doxycycline by weight for 7 days, tetanus if tooth fell in dirt, monitor.

Prognosis: Delayed replantation has a poor long-term prognosis. The PDL will be necrotic and cannot be expected to heal. The expected outcome is ankylosis and root resorption. The goal in delayed replantation is to promote alveolar bone growth to encapsulate the replanted tooth.


Charts:

  1. MONITOR = Follow up chart for dental trauma
    1. Follow up intervals: 3 weeks, 6 weeks, 6 months, 1 year, once annually for the next 5 years.
    2. Follow up tests: percussion test, apical palpation test (look and feel for swelling), discoloration test, mobility test, pulpal vitality test, radiographic evaluation (look for periapical pathology and resorption)
    3. Root canal treatment is indicated for the following outcomes of follow up testing:
      1. Pulp tests non-vital.     Dx. Pulpal necrosis.
      2. Lingering pain to cold.   Dx.: irreversible pulpitis.
      3. X-ray shows periapical pathology and the pulp tests non-vital Dx. chronic apical periodontitis.
      4. X-ray shows resorption.   Dx. Internal or external resorption, can take a CBT scan to determine which one.

        Note: transient or remodeling resorption, which is not pathological, but is part of healing, takes place in the few weeks following the trauma. But resorption that begins well after this point is pathological and requires treatment.

      5. Discoloration
      6. Moderate to severe percussion sensitivity after 3 weeks.  Dx. Acute apical periodontitis.
  2. Treatment urgency chart:
    • Acute i.e. needs immediate at tension.: avulsions, alveolar fracture extrusion, lateral luxations, and root fractures.
    • Subacute i.e. delayed treatment is o.k: concussion, subluxation, intrusion, complicated crown fracture i.e. with pulp exposure.
  3. Resorption and healing:
    1. Repair related resorption: sometimes an area develops and then disappears during the healing process.
    2. Infection related resorption: bacteria stimulate the cementoclasts and that could destroy the tooth itself.
    3. Ankylosis: the PDL is injured in a certain area, so all new tissue growth comes from the bony socket and not the PDL, so the bone ends up growing right up against the root surface.
    4. Transient marginal bone resorption: bone breakdown in the coronal portion of the root, and it then regenerates.

II. Primary Teeth

Problem Treatment
1. Enamel Fracture smooth sharp edges
2. Enamel dentin fracture seal with glass ionomer or composite
3. Crown fracture preserve pulp with partial pulpotomy,
with pulp exposure seal pulp with mta, composite on top
4. Horizontal root fracture if coronal displaced-splint or extract
5. Alveolar fracture reposition displaced segment, splint, monitor
6. Concussion: tender to touch: no treatment-observe
7. Subluxation: mobility no treatment-observe
8. Luxation: tooth displaced
  1. Extrusion
    • Minor – reposition
    • Major – extract
  2.  Lateral: tooth displaces horizontally
    • Minor – allow to reposition and remove occlusal interferences
    • Moderate – reposition
    • Major – extract
9. Avulsion do not replant

Resources

  1. For Dental traumatology:
    1. The American Association of Endodontics guidelines and position statements for traumatic dental injuries. The A.A.E guidelines were formulated in 2012 with the cooperation of the International Association of Dental Traumatology and Blackwell-Munksgaard, and subsequently updated in 2013.
    2. The IADT published guidelines in: 2001, 2007, 2012. The 2012 were updated with the incorporation of information from current literature by three multidisciplinary committees on: fractures and luxations, avulsions, and primary teeth with practitioners from endo, pedo, o.s, and g.d on the committees. The update was also based on lit. Review using embase, medline and pubmed from 1996-2011 and the journal of dental traumatology from 2000-2011. www.iadt-dentaltrauma.org
    3. The A.A.P.D guidelines for dental trauma to primary teeth.
    4. Andreasson’s book entitled ‘Traumatic dental injuries – 3rd edition’. www.dentaltraumaguide.org
  2. For Pulp therapy for primary teeth and immature permanent teeth:
    The American Academy of Pediatric Dentistry guidelines for pulp therapy on primary and immature permanent teeth. These guidelines are based on a systematic literature search of medline/pubmed over the last ten years. When data was inconclusive, recommendations were based on expert and consensus opinion from the 2007 joint symposium of A.A.E. and A.A.P.D. entitled “emerging science in pulp therapy”