INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

Shawfekar(KOD)IIUM
January 29 PEDODONTIC ENDODONTICS, VITAL PULP THERAPY AND APEXOGENESIS/APEXIFICATION

2009
[Endo for Primary teeth]

Despite the advances made by modern dentistry, the premature loss of primary and young permanent teeth continues to be common. This handout deals with the conservation of young teeth in a healthy state so that may function as integral components of the dentition.

PEDODONTIC ENDODONTICS, VITAL PULP THERAPY AND APEXOGENESIS/APEXIFICATION

STUDY QUESTIONS FOR 2006 ORAL EXAMINATION: 1. Understand the rationale, technique specifics and proper case selection for direct and indirect pulp caps. 2. Contrast/understand the use of formocresol or glutaraldehyde as a pulpotomy medicament. Discuss concerns, potential complications/advantages and success rates for each. 3. Discuss the rationale, treatment procedures and success rates for apexogenesis and apexification. 4. What are advantages of apexogenesis over apexification? Despite the advances made by modern dentistry, the premature loss of primary and young permanent teeth continues to be common. This handout deals with the conservation of young teeth in a healthy state so that may function as integral components of the dentition. Premature loss of primary teeth may result in: Changes in arch length, resulting in malocclusion. Loss of esthetics Mastication deficits Speech problems Aberrant tongue habits Loss of vitality in young permanent teeth may result in: A poor crown/root ratio A thin root that can fracture A need for additional endodontic procedures A poorer prognosis for lifetime tooth retention

MORPHOLOGY AND DIAGNOSIS

Successful pulpal therapy in the primary dentition requires a thorough understanding of primary morphology, root formation, and special problems associated with the resorption of primary roots. pulp

Differences in primary and permanent tooth morphology

Primary teeth are smaller in all dimensions Primary crowns are wider in M-D dimensions when compared to their crown length Primary teeth have narrower and longer roots in comparison to their crown length and width Anterior primary teeth have more prominent facial and lingual cervical thirds Primary teeth are more markedly constricted at the DCJ Primary molars have a greater occlusal convergence from the facial and lingual surfaces Roots of primary molars have a greater flare that begins nearer the cervix (greater divergence) Enamel of primary teeth is thinner with a consistent thickness of about l mm Primary teeth have relatively larger pulp chambers Primary teeth have relatively higher pulp horns

Diagnosis
As with the adult, a thorough clinical and radiographic examination must be performed. Admittedly, diagnostic tests are of questionable value in the young patient and determination of health or the degree of disease is difficult, with the correlation of clinical to pathological conditions being minimal.

Radiographs
Pulpal and periradicular changes Physiologic resorption/root formation Presence of calcified masses Intraradicular pathosis Pathologic bone and root resorption

Pulp Test
EPT - the pediatric patient's response to EPT is not reliable Thermal test also relatively unreliable Percussion - start with a normal tooth - offers the best reliability Mobility - physiologic resorption must be considered

Pulp Exposure
Vital pulp therapy - small pinpoint exposure Pulpectomy or extraction - in teeth with large carious exposures and uncontrollable hemorrhage

History of Pain
Spontaneous pain usually associated with degenerative pulpal changes Absence of pain not very reliable

INDIRECT PULP CAPPING

Treatment for teeth with deep caries but no clinical evidence of pulpal degeneration or periapical pathology. It is based on the theory that a zone of affected demineralized dentin exists between the outer infected layer of dentin and the pulp. Removal of the infected dentin results in remineralization of the affected dentin, as well as the formation of reparative dentin.

Active caries has 3 layers:

Necrotic soft dentin; non-painful to stimulation; much bacterial contamination Firmer (soft) dentin; painful to stimulation; fewer bacteria Slightly discolored hard, sound dentin; few bacteria; painful to stimulation The procedure involves the removal of the outer layer of dentin containing most of the bacteria. Sealing the remaining lesion removes the bacterial substrate and results in an arrest of the carious process. Reparative dentin formation along with this arrest of the decay process avoids a pulp exposure. Empirically, the reparative and recuperative powers of the pulp have long been recognized and treatments were judged successful. Proper selection of teeth for this treatment increases the rate of success (75 - 100% success rate range).

Technique:
Removal of all caries except that which directly overlies the pulp (large round bur is best) Wash and dry Place calcium hydroxide dressing Seal with ZOE or amalgam Stainless steel band or crown Do not re-enter the restoration to further remove caries (Dumsha and Hovland DCNA 1985) 3

This only further injures the pulp DIRECT PULP CAPPING Like the pulpotomy, direct pulp capping involves the application of a medicament or dressing to an exposed pulp in an attempt to preserve vitality. This procedure has been employed for carious as well as traumatic and mechanical exposures of the pulp. However, with primary teeth, only the accidental mechanical exposure of the pulp should be considered as a candidate. Radiographically and clinically determined success rates are high. As permanent procedures, disagreement exists concerning pulp capping and pulpotomy in mature secondary teeth. It is universally accepted that vital techniques must be employed in teeth with incompletely formed roots having exposed pulps. Once root development has been completed, routine endodontic treatment can be completed. The presence of bacteria is the most important consideration in predicting pulp capping success. The extremely detrimental effect of bacteria emphasizes the importance of utilizing a rubber dam, sterile instruments and placing a restoration that does not permit leakage of microorganisms. Indications Mechanically exposed primary and permanent teeth Traumatically exposed primary (in certain cases) and young permanent teeth Blunderbuss apices Hemostasis is not a problem No history of pain Contraindications Permanent teeth with calcifications in the pulp chamber Carious exposures Excessive hemorrhage Serous or purulent exudate Axial pulpal exposures Spontaneous toothache Radiographic evidence of pulpal or periapical pathosis Agents Many materials and drugs have been employed as pulp capping agents. Calcium hydroxide, however, is generally accepted as the material of choice for pulp capping. If pulp capping fails, there usually remains the option of endodontic therapy. PULPOTOMY IN PRIMARY TEETH This procedure involves the removal of inflamed and degenerative pulp tissue, leaving intact the remaining vital tissue. This tissue is then covered with either a pulp capping agent to promote healing at the amputation site, or an agent that fixes the underlying tissue. The depth of tissue amputation is determined by clinical judgment. Inflamed tissue is amputated in multi-rooted teeth by removing all tissue to the orifices of the root canals. The pulpotomy differs from the pulp cap only in that additional tissue is removed. The formocresol pulpotomy continues to be the treatment of choice for primary teeth with vital carious exposures. Currently, this technique is still widely taught and utilized in clinical practice. The current formocresol pulpotomy technique is a modification of the original method proposed by Sweet in 1930. Indication 4

Inflammation and/or infection is confined to the coronal pulp

Contraindications Non-restorable tooth Primary tooth is nearing exfoliation History of a spontaneous toothache Periradicular pathosis No hemorrhage Uncontrollable hemorrhage Serous or purulent drainage Presence of a sinus tract Technique Anesthesia/RD Caries removal Entire roof of chamber removed using high speed with water spray Coronal pulp removed Chamber irrigated with saline and dried Hemorrhage controlled with moist (almost dry) cotton pellets If hemorrhage cannot be controlled in 5 minutes, consider pulpectomy Blotted cotton pellet with formocresol (or a 1:5 dilution) is placed on pulp stumps for 5 minutes Cement base of ZOE is placed over the fixed stumps Stainless steel or resin crown is placed Follow-up (every 6-12 mo.) Concerns with the "classic pulpotomy technique Histologic and radiographic success reported as low as 50% Formocresol (FC) Is absorbed systemically Elicits an immune response Binds to organ tissues Alternatives/modifications to the classic technique Prepare a 1:5 dilution of FC Dilutant equals 3 parts glycerine to 1 part water Four parts of dilutant: one part FC Reduce the time of fixation to two minutes Other medicaments Glutaraldehyde Some evidence initially indicated that glutaraldehyde should replace formocresol as the medicament of choice for pulpotomies on primary teeth, but it has not proven as effective as first thought. Glutaraldehyde is an alternative, but most clinicians are continuing to use formocresol. The application of 2-4% glutaraldehyde has the following effects: 5

Rapid fixation of tissue Limited depth of penetration Remaining root canal tissue remains vital

Glutaraldehyde does not perfuse the pulpal tissue to the periapex and will demonstrate less systemic distribution immediately after application. It has a very low affinity for tissue binding and is readily metabolized. The toxicity of the drug is low. In fact, 500 times the amount applied in a pulpotomy procedure causes little if any toxic effects. When compared to formocresol, the antigenicity of glutaraldehyde is low. Indications, contraindications and technique for the glutaraldehyde pulpotomy are the same as the formocresol pulpotomy, with glutaraldehyde being substituted for formocresol. In light of the evidence, perhaps the substitution is justified. Ideal concentrations or time of application, however, have not been conclusively established. Calcium hydroxide Although calcium hydroxide is the preferred medication for vital pulp therapy in the permanent dentition, it is not the recommended agent for pulpotomies in the primary dentition. Failures have been attributed to chronic pulpal inflammation and the frequent development of internal root resorption. Yet, seventy percent of the pediatric dental departments in Scandinavia prefer calcium hydroxide for pulpotomies of primary teeth. Further investigation is warranted. Other Alternatives Electrosurgery Laser Current acceptance of various pulpotomy techniques Avram DC, Pulver F. Pulpotomy medicaments for vital primary teeth. Surveys to determine use and attitudes in pediatric dental practice and in dental schools throughout the world. J Dent Child 1989;56:426-34. Worldwide - FC; 67% (Full strength 34%) - Ca(OH)2; 17% (Scandinavian schools) - Glutaraldehyde; 9% U.S. and Canada - FC; 94% (Full strength 48%) PULPECTOMY IN PRIMARY TEETH In order to perform a successful pulpectomy in primary teeth, the clinician must have a thorough knowledge of the anatomy of the primary root canal system and the variations that exist in these systems. Primary root canal anatomy Maxillary incisor Root wider M-D than B-L Root exhibits a mesial developmental groove and distal concavity No demarcation between pulp chamber and root canal Maxillary canine 6

Pulp space has three pulp horns and a marked constriction in apical 1/3 Maxillary first molar Large MB pulp horn (easy to expose) Divergent roots; palatal largest and DB the smallest By far the most difficult tooth to instrument Maxillary second molar Resembles permanent first molar (both crown and root canal system) MB is largest with longest pulp horn Mandibular incisor Pulp space conforms to external surface Least often cariously involved Mandibular canine Root exhibits a sharp apex with slight curve to distal Sharp apical constriction; therefore it is easy to lose apical matrix during canal prep Mandibular first molar Root canal resembles mandibular 1st permanent molar Pulpal floor is arched in M-D dimension (easy to perforate) Mandibular second molar Root canal resembles mandibular 1st permanent molar 5 pulp horns; MB and ML most prominent Mesial root is wide B-L and thin M-D with 2 canals Pulpal floor is arched in M-D dimension (easy to perforate) Role of resorption on canal anatomy and apical foramina Because of the position of the permanent tooth bud, physiologic resorption of the roots of primary incisors and canines is initiated on the lingual surfaces in the apical third of the roots. In primary molars, resorption begins on the inner surfaces of the roots, and as resorption progresses, the apical foramen may not correspond to the anatomic apex of the root. In fact, it may be coronal to it. In addition, the resorption can extend into the root canals creating additional communications with the periapical tissues. Permanent tooth bud The effects of endodontic therapy on the developing permanent tooth bud should be of paramount concern to the clinician. Since the permanent tooth bud lies immediately adjacent to the apex of the primary tooth, it is advisable that the working lengths of endodontic instruments be 2-3 mm short of the radiographic apex. Rationale for pulpectomizing primary teeth Cost effective Ideal space maintenance High success rates (Rabinowich) Indications Irreversible pulpitis of radicular pulp Necrosis of the radicular pulp Abscessed tooth Periapical and/or pulpal pathosis Contraindications Non-restorable tooth Internal resorption Tooth expected to exfoliate shortly 7

Teeth with extensive pathologic (>1/3) root resorption Extensive pathologic bone loss Perforations of the chamber floor Presence of a dentigerous or follicular cyst Access openings Primary incisor teeth may require access through the facial surface in order to avoid discoloration caused by the escape of hemosiderin pigments into the facial dentinal tubules. The only variation from lingual access is that there is more extension to the incisal edge. Posterior access openings are essentially the same as the permanent teeth. Since the crowns are shorter and more bulbous, the depth for chamber penetration is much less than the permanent teeth, and the distance from the occlusal surface to the pulpal floor is much less. Care should be taken not to perforate the arched pulpal floor. Technique Anesthesia (as required) and rubber dam Complete access and removal of all contents the pulp chamber using a high speed bur and copious water spray (#4 round bur). Removal of radicular pulp with broaches and files. Avoid forcing any infected contents out/through the apical foramen Working length is at least 1-2mm short of radiographic apex. May be shorter depending on physiologic root resorption The intent of instrumentation is the careful removal of the majority of the radicular pulp. Due to the thinness of root walls, the ability to shape the canal is compromised. The goal for an apical matrix is a #30-35 file (Max central incisors may approach #100). Coronal flare is accomplished using Hedstrom files with anticurvature filing to prevent perforation of the inner aspects of the furcation Copious amounts of NaOCl are used to irrigate/debride radicular canal system Dry with paper points. if tooth dries easily, proceed to obturate if time and patient cooperation permit (see below) If second visit will be necessary, place CaOH (especially if canals will not dry well) and a cotton pellet Access is sealed with ZOE Tooth is reentered in 3-7 days Removal of cotton pellet, irrigation and complete instrumentation (if necessary) Obturate tooth, if asymptomatic and canals can be dried. If not, remedicate and seal for another 7 days. Repeat as necessary, but consider that more resorption may be present than radiograph indicates if tooth continues to be symptomatic or contaminated upon opening. In this case, extraction may be required If succedaneous tooth is present, use resorbable filling material such as ZOE paste. CAUTION: do not use reinforced ZOE preparations, such as IRM. They will not resorb and will interfere with eruption of succedaneous tooth. If succedaneous tooth is not present, obturate with gutta-percha and sealer ZOE paste can be placed in canals using pressure applied with a wet cotton pellet, a #5-7 vertical plugger, Lentulo-spiral, or pressure syringe. Anterior teeth are much easier to obturate than posterior teeth. Small amounts of extruded ZOE will be resorbed and are of minimal concern Restoration of the tooth SSC is restoration of choice Composite crowns/build ups may be considered for anterior teeth, remaining tooth structure permitting 8

Periodic follow-up APEXOGENESIS As defined by the AAE, apexogenesis is the physiologic development and formation of the root-end. This term is more frequently used to describe a therapy attempt designed to maintain pulpal vitality and allow it to do what it was primarily designed to do grow dentin. Adequate dentinogenesis is key to physiological strengthening and development of the root of an immature tooth. Unfortunately, the term apexogenesis focuses on growth of the rootend, which is only a single aspect of the total root. Perhaps the term coined by Senia, maturogenesis, describes the process better. Our intent is not merely to close an apex, but also to increase lateral wall dimensions and produce a stronger root. Too often, apexogenesis of immature pulps is terminated as soon as the apical constriction has converged sufficiently to prevent gutta-percha over-extension of GP in other words, too soon. Patience and proper therapy duration are essential to the longevity of these teeth. Thus, the whole tooth concept drives the primary treatment objective with apexogenesis: to strengthen the entire root and not merely to close an apex. Weak roots are much more prone to cervical horizontal and vertical root fracture. Note that the primary difference between apexogenesis and apexification is that some amount of vital pulp is needed for apexogenesis, whereas apexification refers to a treatment method for a tooth with a completely necrotic pulp. The major similarity between the two is that each involves endodontic management of an immature tooth. When pulpal vitality is lost in an immature tooth, the root ceases to grow; the result can be a thin, short root, with an open apex. Open apex types include: Blunderbuss Apical diameter is greater than the coronal diameter Also known as reverse taper or apically divergent Non-blunderbuss Parallel walled or slightly apically convergent Still quite immature Possibly apically divergent, despite radiographic appearance of convergence Most roots are widest in F-P (L) dimension Each aspect of endodontic management of the immature root is more complex than management of a mature root. Being obviously the more physiologic and preferred alternative, apexogenesis should be attempted whenever the pulpal vitality is in doubt. One of the problems in dealing with an apexogenesis scenario is that dentists encounter this infrequently, and are unfamiliar with the principles of management. The consequences are often considerable: Pulpal exposure of immature, permanent tooth (vital pulp) Inexperience with managing scenario Confusion of biologic principles High potential for professional mismanagement Inappropriate treatment Complete pulpectomy or Use of caustic chemicals on vital pulp Significant reduction in long-term prognosis for tooth!

Factors Essential to Pulp Survival following a Traumatic Pulp Exposure Stage of root development Immature apices have greater blood supply and ability to heal Type of periodontal injury Luxation (displacement) injuries cause the greatest pulpal vascular disruption Concussion and subluxation infrequently result in pulpal necrosis

Pulps preexisting health Healthy Previously unstressed, unexposed, uncompromised Excellent prognosis Unhealthy Previously injured by bacterial invasion into dentin or restorative dentistry events (e.g. heat, desiccation) Guarded prognosis Quality of coronal seal Choice of capping material

Factors Not Essential to Pulp Survival following a Traumatic Pulp Exposure Exposure size Exposures as large as 4 mm often survive Duration between injury and treatment Delays as long as 90 days can survive Exposed pulps do not survive indefinitely however! Dont write off pulps with large exposures and lengthy treatment delays!

Diagnosis of Pulpal Necrosis Difficult in the immature, recently traumatized tooth Reliability of responses in child patient is suspect EPT/thermal responses unreliable in immature teeth Immature pulps consist largely of C-neurons C-fibers do not respond well to electricity As apex begins to close, A-delta neurons enter pulp and myelinate A-deltas respond well to electricity and cold/heat Present in sufficient numbers 2-3 years post-eruption EPT/thermal responses unreliable immediately after trauma Transient paresthesia Can persist for many months, up to one year Percussion tenderness should be viewed with caution Could be apical periodontitis due to the periodontal injury (e.g. concussion) May be significant if very tender and adjacent teeth are WNL Apical radiolucency is normally present on immature tooth Easily confused with developing pathosis Compare with contralateral tooth Pulpal hemorrhage and sensation (where exposed) are good indicators of vitality It is essential to consider more than one diagnostic criterion in order to establish success or No single finding or test should stand alone Sometimes, diagnostic uncertainty exists after your work-up If in doubt, watch and wait Give the immature pulp a chance! Protect exposed dentin Improve chances of more dentin deposition Even an inflamed pulp can produce some dentin May perform apexification later, if necessary Do not pulpectomize unless obviously necrotic! Purulent discharge (swelling, sinus tract) Significant spontaneous pain, percussion tenderness, mobility Coronal discoloration Lack of exposed pulp sensation/hemorrhage

failure!

10

Definite pulpal or periradicular pathosis Initiate apexification procedures! Three procedures can protect/preserve pulpal vitality and function in an immature tooth the direct pulp cap, the complete (or cervical) pulpotomy and the partial (or Cvek, or shallow) pulpotomy.

Direct Pulp Cap Exposed pulp is covered with dressing that protects pulp from additional injury Permits healing and repair Acceptable form of apexogenesis treatment Effective for small pulp exposures treated within several hours Advantages Straightforward Less technique sensitive More appropriate for behavior management patients Disadvantages Does not remove contaminated/inflamed zone of pulp Capping material placed directly upon zone of contaminated/inflamed tissue Calcium hydroxide does not benefit inflammation Minimal space remains over cap site for restorative material thickness Adequate thickness necessary for good coronal seal

Pulpotomy Surgical removal of coronal pulp tissue Protects and preserves vitality of remaining coronal/radicular pulp tissue Complete pulpotomy Advantages Provides good thickness of intermediate base and restorative material Effectively protects operational area Disadvantages Dentin will no longer form in cervical region of tooth Crown strength needed to prevent fractures Ability to pulp test no longer remains Natural color and translucency of crown are lost Occasionally necessary due to a wide zone of inflammation Unable to achieve hemostasis following partial pulpotomy Carious exposure in immature tooth Partial pulpotomy Effective for larger exposures and those exposed for hours-days before treatment Advantages Removes contaminated/inflamed zone of pulp Continued dentin apposition in cervical region of tooth Retains root strength in critical, fracture-prone region Preservation of cellrich coronal pulp tissue Improves overall pulpal healing potential Potential remains to perform pulp tests Natural color and translucency of crown are preserved

Disadvantages Technique sensitive Rare pulpal complications 11

It is clear that calcium hydroxide stimulates the deposition of a dentin bridge. Either hard-setting or non-setting paste types of calcium hydroxide may be used for pulp capping and pulpotomy procedures. Great debate has flourished regarding the mechanism of action of Ca(OH)2. Several theories have been proposed: (1) Ca(OH)2 has osteogenic potential; (2) the alkaline pH of Ca(OH)2 favors the formation of alkaline phosphatase (which favors calcification) and inhibits the formation of acid phosphatase, which is present during resorption; (3) Ca(OH) 2 is highly antimicrobial, making the environment favorable for healing in all tissues; (4) its small particle size may stimulate calcification, and (5) Ca(OH)2 causes limited tissue necrosis, which initiates a healing response. The exact answer is unknown, but probably involves a combination of several ideas. A newer material, mineral trioxide aggregate (MTA), also stimulates dentin formation; prevents bacterial leakage; is effective in a moist environment; and is biocompatible.

Calcium Hydroxide Formulations Pastes Release twice as much calcium as hard-setting bases Antimicrobial properties are similar to pure reagent Produce a necrotic zone ~0.5-1 mm deep Evident as radiolucent zone between Ca(OH)2 and the developing dentin bridge Allows visualization of the bridge Often seen as early as 3 weeks after dressing placement Hard-setting bases Less calcium is released and less tissue necrosis occurs Dentin bridge forms almost directly against base No radiolucent zone of necrosis is evident Dentin bridge is very difficult to detect radiographically

Dentin Bridge Formation Bridge development is a favorable (but no guarantee) sign of healing Histologic quality is the same, whether stimulated by paste or hard-setting base Structural defects exist Through-and-through soft tissue inclusions are numerous Permeable to bacteria and their products Periodic evaluation of coronal restoration essential Ensure material integrity/marginal adaptation, and absence of caries

Apexogenesis Prognosis Success following complicated crown fracture (traumatic pulp exposure) Partial pulpotomy 94-96% True for immature and mature teeth alike Direct pulp cap 80% for closed apex; 90% for open apex Pulpal Reaction to Carious Exposure Bacteria are directly responsible for failure of injured/exposed pulps to heal In the absence of bacteria, injured pulps can heal completely Preexisting, deep pulpitis exists by the time bacteria reach pulp Pathosis intensifies considerably when bacteria reach to within 0.5 mm of pulp Calcium hydroxide is irritating and has no beneficial effect on preexisting inflammation Success following carious exposure Partial pulpotomy 94% for patients who are asymptomatic before treatment 12

66% for patients who are symptomatic before treatment A viable treatment option for immature, cariously exposed tooth! Practical recommendations Perform a complete (cervical) pulpotomy Zone of inflammation is often deeper than 2 mm when due to caries Complete the endodontic therapy following adequate root maturation Direct pulp cap very unpredictable Case selection is critical Not recommended!

Informed Consent Overall apexogenesis treatment duration Up to 2-3 years If waiting to a fabricate post-core and crown restoration Follow-up requirements/reliability Multiple recalls needed Care/maintenance of coronal seal May need to replace restoration Possibility of pulpal necrosis, calcific metamorphosis, internal resorption

Pulpal Reaction to Traumatic Exposure (Healthy Pulp) Hemorrhage and contact with oral bacteria Superficial (2 mm) inflammatory response following traumatic exposure Response remains superficial for up to at least 7 days after exposure Rationale for a 2 mm Cvek pulpotomy Pulpal hyperplasia (polyp) is occasionally seen at the exposure site Deep (> 8 mm) inflammatory response following cavity preparation and contamination Food/debris pack into void Pulpal abscess formation invariably occurs

Direct Pulp Cap Technique Achieve anesthesia Isolate Occasionally a split RD technique is necessary, due to incomplete eruption Cotton roll Fracture site is cleaned and dried Exposed pulp and dentin are covered with dressing of hard-setting calcium hydroxide Fractured surface is acid etched and restored with bonded composite resin Follow up for response to therapy Partial Pulpotomy Technique Achieve anesthesia Avoid pulpal injury, i.e. do not use intrapulpal anesthesia Isolate Disinfect exposed dentin Perform partial pulpotomy Excise any extruding pulpal tissue 13

Remove coronal pulp tissue to a depth of ~ 2mm below exposure Use new diamond bur and light brush strokes Flush copiously with sterile saline Consider entire mesio-distal width vs. limited area pulpotomy Achieve hemostasis Apply gentle pressure with saline-soaked cotton pellet If no hemostasis after 5 minutes, remove additional pulp tissue Do not use hemostatic chemicals or air dry pulp These cause additional tissue damage Remove any extra-pulpal blood clots These act as a barrier and prevent good calcium hydroxide contact Place calcium hydroxide Use soft consistency medication, so as to not further injure pulp Avoid heavy mixtures, which require condensation Cover entire pulp with at least a 1 mm thickness Hard-setting bases need no intermediate base Paste formulations need an intermediate base Place intermediate base Necessary if using soft paste calcium hydroxide formulation Should be flowable and ideally light-activated Place definitive restoration Acid etch, bonded Essential to prevent coronal microleakage Ideally a single-visit procedure

Followup Monitoring of Apexogenesis Therapy Success can only be monitored through recall Most complications occur during the first post-treatment year Pulpal necrosis Calcific metamorphosis Internal resorption Recommended recall intervals 3, 6, and 12 months, and annually as deemed necessary

Criteria for Success (not all may be present) Clinical findings Absence of signs or symptoms, and coronal seal is intact Responsiveness to EPT/cold May not exist, depending on level pulpotomy was done Response testing is normally unreliable after trauma Transient paresthesia of pulpal sensory receptors Response testing is unreliable until the apex has closed 23 years post-eruption Vital pulps may not experience any sensation! Radiographic findings Evidence of dentin bridge formation Presence/absence depends on type of calcium hydroxide used Not normally seen when hard-setting base form used Presence is favorable, but does not guarantee eventual success Pulpal necrosis may still occur after bridge development Continued root development in immature teeth The most important criterion for success! 14

Compare all radiographs in the treatment series Lateral root wall thickening Reduction of pulp cavity dimensions Lack of size change suggests pulpal necrosis Apical lengthening and convergence No periapical pathosis Apical radiolucency is normally present with immature tooth Compare with contralateral tooth

Disposition following Completion of Apexogenesis Two controversial schools of thought Once root maturation is complete, perform RCT automatically An attempt to forestall late complications All are very infrequent Pulpal necrosis Canal calcification Internal resorption Provides space for post and core Perform RCT after apexogenesis only when needed Pulpal necrosis and internal resorption are rare Histology is normal after a partial pulpotomy Space required for a post and core A compromise option Where surgical access is straightforward (e.g. anterior teeth) Follow case and perform RCT only when specifically indicated Where surgical access is difficult Perform RCT routinely following complete root maturation

APEXIFICATION
When the pulp of an incompletely formed tooth loses its vitality, then the entire root system has also lost its ability to continue to develop. Only viable, functional odontoblasts have the ability to form dentin. If doubt exists regarding pulpal vitality, as oftentimes may be true with immature teeth in immature patients, treat the tooth with an apexogenesis procedure initially, and follow the case closely. As defined by the AAE, apexification is a method of inducing a calcified apical barrier of an incompletely formed root, in which the pulp is necrotic. Only the root apex is affected by apexification procedures. Various final apical morphologies may result. Generally, the apex assumes a blunt form. Lateral wall thickness and overall root length will not increase. Clinical Dilemma Managing the Pulpless, Permanent Tooth with a Wide-Open, Immature Apex Problems Larger apical versus smaller coronal canal diameter (reverse taper) Increased difficulty of debridement Greater canal wall surface area compared with smaller canal Lack of an apical stop renders safe obturation impossible Cannot control extrusion of obturating materials Thin root walls are forever prone to fracture Short root contributes to a poor crown-root ratio Surgical Resection/Root-End Fill (Historical) Disadvantages Thin dentinal walls often fractured during preparation 15

An already poor crown-root ratio was made worse Psychologically very traumatic for child patient

Nonsurgical, Apical Closure Alternatives (Contemporary) Each provides a matrix against which GP and sealer can be compacted Customized GP obturation (immediate) Canal must be apically convergent and have a path of draw Not appropriate for blunderbuss (reverse taper) apex Placing an artificial barrier (immediate) Mineral trioxide aggregate Tricalcium phosphate Freeze-dried bone Apexification (long-term) Canal is cleaned and filled with temporary, bioactive material Material stimulates differentiation of connective tissue cells Cells deposit a calcified barrier across apex opening Location of barrier is related to level of filling material Barrier consists of osteoid and cementoid tissue types Contains minute foramina, which communicate with periapical tissue Contiguous with lateral root surface Bioactive material is removed after adequate apical closure occurs Canal is obturated with guttapercha and sealer

Materials Used to Successfully Stimulate Apexification Calcium hydroxide alone Calcium hydroxide mixed with other active agents, or inactive vehicles Methylcellulose Camphorated parachlorophenol (CMCP) Metacresyl acetate Cresanol Physiologic saline Ringers solution Distilled water Anesthetic solution Zinc oxide pastes Antibiotic pastes Tricalcium phosphate Mineral trioxide aggregate There seems to be little justification for mixing Ca(OH)2 with other active medications (all of which are toxic). The desired beneficial effects are effectively provided by calcium hydroxide alone. Ca(OH) 2 can be mixed with many solutions to aid its delivery, but the mixture with methylcellulose, commercially sold as TempCanal by Pulpdent, is a product that is easy to apply, easy to replace and radiopaque. Successful apexification has been shown to occur without any canal filling material at all, as long as removal of the necrotic pulp tissue is complete! Thorough debridement and sealing of the root canal appear to be the most important factors for success. Apexification Prognosis Short-term success Excellent (approaches 100%) Failures have been shown to be due to poor canal debridement 16

Most commonly in apically divergent teeth Long-term success Guarded Root lacks lateral wall thickness and is weak Cervical root fracture is common Vertical root fracture is common

Informed Consent Overall treatment duration 6-24 months (average = 1 year) Increased treatment time associated with certain factors Radiolucency Interappointment symptoms Loss of coronal seal Follow-up and patient reliability requirements Multiple appointments are necessary Care of coronal seal Compromised, resulting root strength Adverse effect on function, fracture potential and long-term prognosis

Apexification Technique Anesthesia and RD isolation The use of no (or minimal) anesthesia is recommended for all apexification appointments, when possible. Obviously, discomfort from remaining vital pulp tissue, hydraulic conductance of sensations to periradicular tissues or from rubber dam clamp placement may preclude this. When the patient is fully sensate, he/she can feel/advise when the calcium hydroxide is just beginning to contact periradicular tissues. Towards completion of the apexification timeline, the patients sensation can also help in the assessment of barrier formation, during testing of its solidarity through tactile probing. Access Made as usual in shape and position, but notably larger than that made for a mature tooth Size extension is needed for the larger instruments (oftentimes > size #100 file) used, and the increased chamber size/pulp horns of oftinvolved, younger tooth Additional incisal extension is needed in anterior teeth, to allow instrument contact with P (L) wall Large files are often too inflexible to pre-bend Large necrotic pulp should be removed using broaches or Hedstrom files Working length Determined radiographically Electronic apex locators are less accurate when the apex is open Strive for 12 mm short of apical extent of root wall Stabilize WL instrument with cotton pellet for making radiograph

Canal debridement Perform as thoroughly as possible Full strength sodium hypochlorite is desirable and not contraindicated Use caution not to over-insert or bind irrigation device Use silicone stop or bend irrigation probe short of WL Irrigate passively! 17

Canal is often apically divergent Use instruments, which are narrower than coronal canal diameter Lean files toward all wall surfaces Circumferential filing P (L) canal wall is often incompletely debrided Be gentle on thin, fragile dentin walls Use a low pressure, brushing motion Avoid instrumentation beyond apex Sonic and ultrasonic devices are helpful (if available) Canal drying Invert coarse/extra coarse paper cones Measure/set paper cones to proper WL and avoid overinsertion Avoid stabbing periradicular tissues Placement of calcium hydroxide Due to the difficulties with material removal, hard-setting Ca(OH)2 formulations (e.g. Dycal) are not used for apexification. Pure Ca(OH)2 powder may be placed using an amalgam carrier or Messing Root Canal Gun, and compacted using endodontic condensers or paper/guttapercha points (large end). Length control should be used for all condensers to prevent overextension, and tissue injury. Ca(OH)2 powder/methylcellulose paste mixtures are a manageable, putty consistency, and may be both placed and compacted using appropriately sized endodontic condensers. Any of the paste formulations (e.g. Pulpdent, TempCanal and Multi-Cal) or saline/aqueous solutions (e.g. Calasept and UltraCal XS) may be syringed into the pulp chamber (or into canal if of sufficient size) using an appropriately gauged needle and silicone stop, set 2-3 mm short of WL. The material may then be fully delivered to preparation length and applied to the canal walls using a low-speed handpiece and lentulo spiral filler (operated in a forward direction). Ca(OH)2 should contact apical tissues for proper biological activity to occur. The canal should be filled with the paste, but not intentionally overfilled. The response of the patient is used as a guide in approaching the apex. Radiographic checks are helpful to verify adequate filling. If the canal is unintentionally overfilled, no attempt is made to remove the material. The presence of an overfill rarely causes post-operative pain. Any tissue reaction will quickly subside. Sealing the coronal access A small cotton layer is placed over the Ca(OH)2, which often creates some hydraulic pressure and patient sensation. Apply the pellet slowly and warn the patient. Use a permanent restorative material (composite, amalgam or GIC) or reinforced ZOE (e.g. IRM) to seal. Do not use short term closure materials, such as Cavit. If the outer seal becomes defective, the calcium hydroxide will be lost and the canal will become recontaminated. Radiograph the tooth after the rubber dam has been removed. Periodic recall Recall is key for any long-term therapy, to ensure that what you desire to happen is actually happening. Following the first Ca(OH)2 placement appointment, the patient should be seen again in 4 weeks for paste removal and replacement. At this time much of the material will have dispersed (washed out) and residual pulpal tissue will have dissolved and be ready for total removal. Following this visit the patient should be recalled every three months and evaluated for the need to replace the Ca(OH)2, as well as the progress of barrier formation. The integrity of the access restoration must be critically ascertained, especially when it will be retained for another recall interval. Make a pre-operative radiograph (and post-operative radiograph if a paste change is performed). Additionally, perform a complete signs and symptoms evaluation. If signs/symptoms develop during follow-up, the canal should be debrided and refilled. If at followup the paste appears radiographically dense and the closure is progressing, there is no need treat the tooth. If radiographic evidence of paste dispersion and loss from the canal is seen, the canal should be debrided and again filled. Continue recalling until radiographic evidence of apexification becomes apparent. The tooth should then be reentered and the barrier evaluated using gentle, tactile probing with a size #20-25 file. Alternately, the barrier may be sounded using a corresponding paper cone. Avoid plunging any instrument beyond the apex, as this would disrupt the developing apical barrier and delay the apexification process. It is not necessary for 18

complete resolution of a periradicular radiolucency to occur, prior to completion of apical barrier formation. The end-point of apexification has been achieved when the #25-30 file does not penetrate the barrier (using light pressure), the patient experiences no sensations to barrier probing and the canal can be completely dried. If apexification is incomplete, the canal is repacked and the recall continued. Obturation Once barrier development is believed to be sufficient to withstand GP compaction forces, the canal may be obturated using GP and sealer. For oversized (size #140), apically convergent canals, the master apical impression (customized) technique is appropriate. For irregular, parallelwalled or reverse taper (apically divergent) canals, a thermoplastic technique is necessary.

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