Australian Dental Journal, October, 1979 341

Volume 24,
No. 5

Endodontic treatment of primary teeth

Kevin R. Allen, B.D.S., Cert.Ped.(lll.), F.I.C.D.

Senior Lecrurer in Children's Dentistry, The University of Adelaide

ABSTRACT- Endodontic treatment of primary teeth is undertaken by indirect pulp capping, direct pulp
capping, formocresol pulpotomy and pulpectomy. The same treatment principles apply to both primary
and permanent teeth with infected or necrotic pulps. The main differences are the use of formocresol for
root canal medication and a resorbable zinc-oxide and eugenol paste for root canal obturation.

Although dental caries in children has been reduced
by water fluoridation and an increased parental
awareness of the causative factors, there are still many
children with primary teeth which require pulp therapy.
As the primary teeth are the best space maintainers, teeth
with affected and infected pulps should be retained until
exfoliation, whenever possible.
The reparative potential of the pulp is much greater
than formerly believed. Consequently, many teeth with
affected pulps have been saved by vital pulp therapy using
pulpotomy or direct and indirect pulp capping tech-
niques.'
The idea that a painful pulp is a dead pulp is a
misconception because :-
(1) Clinical symptoms of pain are very poor indicators
of pulpal status. Numerous histologic studies have shown
little correlation between the clinical appearance of deep
carious lesions, symptoms of pain and pulpal pathosis.
(2) Failure to distinguish between dentinal pain and
pulpal pain can contribute to an incorrect diagnosis.
Dentinal pain is characterized by a sharp lancinating
quality, evoked by mechanical and chemical agents
such as sugars and acids. Pulpal pain is characterized by
a more continuous, dull throbbing ache which is in-
creased by heat or lying down.
(3) The idea that every pulp under a deep or superficial
carious lesion is infected is vigorously denied. Thousands
of histologic sections of pulps under deep, active
(painful) carious lesions show that the pulp is not infected
at all and only mildly inflamed.'
The pulp of a tooth under a deep carious lesion with a
distinct layer of tubular dentine still present between
the pulp and the bacterial plaque is often inflamed and
very painful but contains very few, or no histologically
demonstrable bacteria. It is significant that the clinically
acutely painful pulps are usually those affected and
inflamed-but not yet infected. In contrast, the infected
and necrotic pulp yields a history of lesser pain-chronic
and in the past-but rarely severe or acute pain.*
A diagnosis and treatment plan must be determined
before treatment of the affected or infected pulp is
commenced. Considerations in the diagnosis should
include the child's medical and dental history, the use of
any diagnostic aids and control of pain. Rubber dam
should be used to give the operator a sterile field and
the patient a sense of security.

Massler, M.-Preventive endodontics: Vital pulp therapy. Massler, M., and Pawlack, J.-The affected and infected pulp.
Dent. Clin. North America, 6 6 3 4 7 2 (Nov.) 1967. Oral Surg., 43: 6,929-947 (June) 1977.
348
Pulp treatment of primary teeth should be undertaken
only if it in no way endangers the general health of the
patient. It should not be carried out in children with
cardiac abnormalities such as rheumatic heart or con-
genital heart defects. The failure of pulp therapy may
produce a focus of microbial infection which may
further affect the diseased condition. It should also be
avoided on severely ill and debilitated ~ h i l d r e n . ~
The operator must be aware of the history of pain.
Has there been an absence of pain or pain only for short
periods, or has pain been present for a prolonged period
of time? Has the pain been a chronic dull pain for several
days or a severe throbbing pain? Has the pain occurred
on reclining or during sleep? Has the pain occurred on
percussion, during mastication or because of food
impaction? Has the pain arisen due to hot or cold foods
and liquids or sweet and sour foods? Wei3 has listed the
subjective symptoms of pain as:-
A . Unfavourable
1. pain for prolonged periods of time;
2. severe throbbing pain;
3. pain due to sweet and sour foods;
4. pain on reclining or during sleep;
5. chronic dull pain for many days;
6 . sensitivity to percussion.
B. Favourahle
1. absence of pain or pain for brief periods;
2. pain caused by cold liquid or cold foods only;
3. pain due to sweets and sour foods;
4. pain due to food impaction.
A recent periapical radiograph must be checked for
any periapical changes or evidence of calcified masses
in the pulp. The value of the electric pulp test on primary
teeth is questionable although it will give an indication
of whether the pulp is vital. The test does not give
reliable evidence of the degree of inflammation of the
pulp. The reliability of the pulp test may also be
questioned as once the test has been used an apprehensive
child, may give a false response to both heat and the
electric test.4
The comfort and lack of apprehension of a child
must be paramount in any discussion of operative
procedures. The use of local anaesthesia is indicated and
relative analgesia is helpful for the apprehensive patient.
In some instances it is possible to complete a vital
pulpotomy using only relative analgesia without local
anaesthesia.
One of the main reasons for using rubber dam in
restorative procedures for children is that it has a
comforting effect so that many fall asleep during treat-
Full. C. A,, Johnson, R., Parkins. F. M., Walker, J. D., and
Wei, S. H. Y.-Pedodontic diagnosis and treatment self-
instruction syllabus. Iowa City, The University of Iowa,
1972 (pp. 67-76).
McDonald, R. E., and Avery, D. R.-Dentistry for the child
and adolescent. Saint Louis, The C. V. Mosby Company,
3rd. ed, 1978 (pp. 149-171).
Australian Dental Journal, October, 1979
ment. After placement of rubber dam difficult patients
frequently become co-operative patients; also the
efficiency of the operator is increased and should a pulp
become exposed, a pulpotomy can be performed
immediately.
The method of applying rubber dam as practised in
the Pedodontic Clinic of The University of Adelaide is
described in a previous paper by Allen.5
Treatment
Pulp treatment of primary teeth will be discussed under
four headings.
1. Indirect pulp capping
The objectives of indirect pulp capping as listed by
Wei3 are:-
(a) preserve the vitality of the pulp
(b) prevent direct exposure of the pulp
(c) promote secondary dentine formation by odonto-
blasts
(d) promote remineralization of the demineralized
layer.
Indirect pulp capping is a two-appointment pro-
cedure. It should be completed on teeth with deep caries
where there has been an absence of pain.
_.
At the first appointment the superficial necrotic
layer of carious dentine along the dentino-enamel
junction is removed. The affected. deeper, demineralized
layer of dentine which is not infected is not removed.
There has been controversy as to whether a base of
calcium hydroxide or a zinc oxide and eugenol prepara-
tion should be the agent of ~ h o i c eThis
. ~ is unimportant
as the defense mechanism of living dentine against
injury is by sclerosis of vital tubules under the lesion with
partial remineralization of the demineralized dentine.6
I t is imperative that the cavity seal is maintained with a
temporary or intermediate restorative material such as
IRM,* a temporary filling made by mixing silver alloy
filings with zinc phosphate cement or an amalgam
restoration. If there has been gross destruction of the
tooth a preformed or pinched stainless steel band is
adapted and cemented to the tooth.
At the second appointment in approximately three
months, the intermediate restoration and sterilized
carious dentine are removed. The demineralized dentine
is removed until a hard cavity floor is achieved which
may still exhibit staining. A regular cavity base is placed,
* L. D. Caulk Co.
Allen, K. R.-Restoration of the extensively carious primary
molar. Austral. D. J., 16: I , 8-12 (Feb.) 1971.
Eidelman, E., Finn, S. B., and Koulourides. T.-Reminera-
lization of carious dentine treated with calcium hydroxide.
J. Dent. Children, 32: 218-225 (4th Quarter) 1965.
Australian Dental Journal, October, 1979
followed by copal varnish and the final restoration of an
amalgam or stainless steel crown.
It has been shown that a 10 per cent stannous fluoride
solution when applied to carious dentine promotes
remineralization of the residual dentine. Furthermore,
it has also been shown that stannous fluoride indirect
pulp capping is superior to calcium hydroxide because
the former increases the radiodensity and the hardness
of the residual dentine.3
When using 10 per cent stannouSfluoride the solution
is applied for five minutes to the demineralized dentine
after removing the superficial necrotic layer of dentine
and caries along the dentino-enamel junction. A
temporary restoration, IRM or amalgam is placed. The
second appointment is as described previously.
The use of indirect pulp capping will maintain the
vitality of many teeth, preventing unnecessary endo-
dontics.
2. Direct pulp capping
Because of the poor success rate when calcium
hydroxide is used as a pulp capping agent and the high
success rate of formocresol pulpotomy, it is rare for the
direct pulp capping procedure to be used in the treatment
of primary teeth. The only occasion when it should be
considered is after a minimal mechanical exposure such
as occurs when the patient bites the handpiece. Im-
mediately after the exposure place a pellet of sterile
cotton wool moistened with sterile normal saline or
anaesthetic solution to prevent drying of the exposed
pulp. Flow calcium hydroxide over the exposed pulp and
if the cavity has been prepared, place a temporary dress-
ing of zinc oxide, IRM, amalgam or composite
restoration. A periapical radiograph is taken if a recent
film is unavailable.
After six to eight weeks the exposure site is inspected
to determine the extent of dentinal bridging. If the
healing is complete, the tooth is restored with amalgam
or composite. If healing is incomplete, the site is flushed
with sterile normal saline and again treated.'
3. Formocresol pulpotomy
Formocresol vital pulpotomies of primary teeth is the 4. Pulpectomy
treatment of choice when the pulp has a carious or a
large mechanical exposure. The contraindications to pulpotomy has been used in treating many teeth with
treatment which have been listed by Brauer" and FinnQ necrotic or degenerating pulps, the success rate is not as
are :-
(a) the tooth is mobile and about to be exfoliated;
' Bonus, H. W.. and Anderson, A. W.-Clinical andlaboratory
handbook for pediatric dentistry. Chicago, Department of
Pediatric Dentistry, The University of Illinois, 2nd revision. increasingly used in incisor and canine teeth in the
March, 1977 (pp. V1, 1-10).
Brauer, J. C.-Dentistry for children. New York, McGraw-
Hill Book Co., 5th edn, 1964 (pp. 463-478).
Finn, S. B.-Clinical Pedodontics. Philadelphia, W. B.
Saunders Co.. 4th edn. 1973 (pp. 201-218).
349
(b) the patient is in poor health and his resistance to
infection is low: e.g., in cases of diabetes, leukaemia,
rheumatic fever, haemophilia;
(c) retention of the tooth is not in harmony with the
occlusion or growth of the jaws;
(d) an acceptable cavity cannot be prepared;
(e) the crown of the tooth cannot be restored;
(f) evidence of periodontal or bone involvement;
(g) internal resorption;
(h) prolonged pain;
(i) a purulent or necrotic pulp;
6) calcified structures in the pulp.
In addition, consideration is given to the following
factors:-
(a) the very young or handicapped child who may be
unable to give the necessary co-operation ;
(b) the time required to complete the operation-
this would apply to treatment under general anaesthesia
and handicapped children;
(c) the cost of the treatment. Parents should be
informed of the fee as well as the success rate, which is
approximately 97 per cent;
(d) if other teeth have been extracted, the desirability
of extracting this tooth and inserting a space maintainer.
There are two different formocresol techniques. A
five-minute one-appointment procedure, or a seven-day
two-appointment procedure. The five minute technique
has been described previou~ly.~
In the two-appointment procedure after removal of
the pulp from thepulpchamberacottonpellet moistened
with formocresol is sealed in contact with the pulp
stumps for approximately seven days. At the second
appointment, the cotton pellet is removed and the pulp
stumps covered with a layer 1-2 mm thick of 50j50 mix
consisting of one drop of formocresol and one drop of
eugenol mixed with zinc oxide to a thick paste. A layer
of thick zinc phosphate cement is placed over the SOj50
layer and the tooth restored with amalgam or a stainless
steel crown.
Although the two-appointment formocresol
satisfactory as treatment with pulpectomy. When a
primary tooth has exhibited spontaneous pain the root
canals are cleansed and a pulpectomy completed.
Alternatively, the tooth is extracted and a space-
maintainer placed, if necessary.
Full root therapy using forms of resorbable paste is
primary dentition. Dissatisfaction with pulp capping
and some pulpotomy procedures in posterior teeth has
also led many practitioners to attempt obturation of root
canal systems in these teeth.9
350
Before commencing a pulpectomy it is essential that
the practitioner is aware of the three-dimensional
anatomy of the root canal systems of primary teeth.
Barker and his colleaguesln have described in detail
these root canal systems. Other factors which need to be
assessed are the age of the patient, the development of
the tooth and the amount of root resorption.
The anterior primary teeth usually have a simple one
canal root system. As resorption occurs more on the
lingual aspect of the root, the anatomical root apex may
vary considerably from the radiographic apex. The root
canal should be obturated to the anatomical apex,
which is a matter of clinical judgement depending on the
amount of resorption.
In 75 per cent of specimens the palatal and distobuccal
roots of the maxillary primary first molars are fused
completely or incompletely by a thin dentino-cementa1
lamina and this contains a complicated meshwork of
canal divisions connecting palatal and distobuccal
canals. Although 58 per cent of maxillary second molars
have a similar tendency to incomplete separation of
palatal and distobuccal roots, three separate roots are
frequently encountered.
In young specimens of mandibular primary first
molars with incompletely formed apices, the roots may
possess single and very wide root canals. Partitioning
results in a meshwork of transverse communications
with maturity. Eventually, each of the two roots may
possess two partially or completely separate canals so
that four canals may be encountered. The primary
mandibular second molar exhibits greater root diverg-
ence than the first molar. Root canals may be single and
very broad in young teeth, but two canals with transverse
communication may eventually separate off in each
root. O
Radiographs show the anatomy of teeth in a
mesiodistal plane but not in a buccolingual plane. The
majority of variations of root canal systems in primary
molars occurs in the buccolingual plane. Radiographs
are therefore a poor tool for viewing the anatomy of root
canal systems. Periapical radiographs are a valuable
aid in diagnosis and also provide a record of the con-
dition of the tooth and surrounding structures.
Contraindications for pulpectomy of primary teeth
are :
~
(a) pathologic root resorption;
(b) the tooth is unrestorable;
(c) the tooth exhibits internal resorption, which is
always larger than the area viewed on the radiograph;
(d) perforation of the pulpal floor which has occurred
due to instrumentation or caries;
(e) mobility if due to the tooth exfoliating
I" Barker, B. C. W., Parsons, K. C., Williams, G. L.. and Mills,
P. R.- Anatomy of root canals. IV. Deciduous teeth.
Austral. D. J., 20: 2, 101-106 (Apr.) 1975.
Australian Dental Journal, October, 1979
Cellulitis with no radiographic evidence of periapical
patholosis, as well as acute exacerbations of chronic
periapical patholosis which show radiographic radio-
lucency or a fistula, are not contraindications for
pulpectomy in primary teeth. These teeth can be treated
by incision of any fluctuant local swelling, a full course of
antibiotic cover and routine treatment by pulpectomy.
In the majority of'cases the tooth is sealed with a
temporary dressing after the initial treatment, but where
there is profuse swelling and exudate the tooth may be
left open for 24 hours. If the infection cannot be con-
trolled by these means, the tooth should be extracted
and a decision made on the necessity of placing a
spacemain tainer.
The technique for pulpectomy of primary teeth is
similar to permanent teeth. The major differences are that
between the first and second appointments formocresol
is used for medication of the canals, and obturation of
the canals is with a resorbable paste of zinc-oxide and
eugenol. As it is impossible to cleanse completely the
root canal systems of primary molars mechanically or
chemically, the objective is to remove pulpal debris
down to a level the body can tolerate.
At the first appointment after administering local
anaesthesia the tooth is isolated with rubber dam. The
pulp chamber is opened so that all the root canals are
exposed; there may be as many as six canals. The pulp
is removed using a barbed broach or a file. The root
length is estimated from the periapical radiograph and
the plastic stops on the files and reamers are adjusted.
The distal root of the mandibular primary molar may
be 2-3 mm shorter than the mesial root as the tooth bud
of the first premolar is situated more under the distal
root. Files are placed in the root canals and a radio-
graph is taken to determine the root length. The canals
are enlarged with small files and during instrumentation
are irrigated with chlorhexidine gluconate solution,t
EDTAS followed by chlorhexidine gluconate solution,
or rc-prefi and sodium hypochlorite. The canals are
dried with paper points and demethylchlortetracycline
hydrochloride pasten introduced into the canals with a
lentulo spiral. A cotton wool pellet is placed in the pulp
chamber and sealed with cavit or IRM. A cotton pellet
moistened with formocresol may be placed in the pulp
chamber instead of using demethylchlortetracycline
hydrochloride paste. Careful filing of the root canal
should be practised to prevent pushing the file through
the apex which could result in trauma to the permanent
tooth bud.
At the second appointment the temporary filling is
removed and the canals are cleansed as previously
described. The paste is removed with small files having
rubber stops adjusted to the corrected length of the
~~-~~
t Snvlon. Imperial Chemlcal Industries of Australia and New Zealand
Limited.
t: Ethylenediemine tetra-acetic acid, Orapharm (Vic.) Pty. Lid.
p Medical Products Laboratories.
7 Lederle Pharmaceuticals
Australian Dental Journal, October, 1979 35 1

canals. The canals are dried and filled with zinc oxide Summary
and eugenol paste without the inclusion of the accelerator Endodontic treatment of primary teeth has been
zinc acetate. The zinc oxide paste is introduced into the discussed under four headings :-
canals by a lentulo spiral, a pressure syringe or mixing (1) Indirect pulp capping.
into a thick paste and packing with root canal pluggers. (2) Direct pulp capping.
A zinc phosphate cement base is placed and the tooth (3) Formocresol pulpotomy
restored with amalgam or a stainless steel crown. (4) Pulpectomy.
Local anaesthesia is not required for the second Although the child may have a local swelling, a
appointment except for a soft tissue anaesthesia before cellulitis, or a fistula due to pulpal necrosis, it is not a
applying the rubber dam clamp. The reaction of the contraindication to pulpectomy in primary teeth. The
patient will determine whether the canals have been same principles of technique apply to the treatment of
filled to the anatomic apex. Subsequently, a periapicai both primary teeth and permanent teeth with infected
radiograph is taken to confirm that the canals have been or necrotic pulps. The main differences are the use of
adequately filled. formocresol for medication of the root canals and a
Radiographic checks should be made regularly at resorbable paste of zinc-oxide and eugenol for root canal
intervals of 1-2 years. As there is a difference between obturation.
the resorption rate of the zinc oxide paste and the tooth
root, small areas of zinc oxide paste may remain as the Department of Dental Health,
root is resorbed. The University of Adelaide,
Primary teeth successfully treated with a pulpectomy Box 498, G.P.O.,
remain as functional units in the dental arch until the Adelaide, S.A., 5001.
time of exfoliation.