endodoncia para niños

Endodontic treatment for childrenP. Carrotte1

Root canal treatment for children has particular difficulties and considerations. It must be planned in light of the remainingteeth, and the need for balancing or compensating extraction borne in mind. Diagnosis may be difficult, as may prolongedtreatment under local anaesthesia and rubber dam. Vital pulpotomy techniques with formocresol and/or calcium hydroxidemust be carefully executed in line with the UK National Guidelines. The treatment of the avulsed tooth has been the subject ofmuch research, and practitioners should ensure that they are up-to-date with current treatment modalities.

1*Clinical Lecturer, Department of AdultDental Care, Glasgow Dental Hospital andSchool, 378 Sauchiehall Street, Glasgow G2 3JZ*Correspondence to: Peter CarrotteEmail: [email protected]

Refereed Paperdoi:10.1038/sj.bdj.4811946© British Dental Journal 2005; 198: 9–15

Root canal treatment in children should only be prescribed after careful consideration of thepatient, the existing dentition, and developing teeth.

Isolation with rubber dam is just as important as with the permanent dentition. Paediatric endodontic treatment may be more directed towards pulpotomy rather than

pulpectomy. All practitioners should be familiar with current guidelines on the treatment of the avulsed

tooth.

I N B R I E F

Although the basic aims of endodontic therapyin children are the same as those in adults, ie theremoval of infection and chronic inflammationand thus the relief of associated pain, there areparticular difficulties and considerations. Thepulpal tissue of primary teeth may becomeinvolved far earlier in the advancing cariouslesion than in permanent teeth. Exposure mayalso occur far more frequently during cavitypreparation due to the enamel and dentine beingthinner than in the permanent tooth, and thepulp chamber, with its extended pulp horns,being relatively larger, as can be seen in theextracted tooth at Figure 1. Primary molar rootcanals are irregular and ribbon-like in shape.Periradicular lesions associated with infectedprimary molars are usually inter-radicular

(Fig. 2) rather than periapical in site due to thepresence of accessory canals in the thin floor ofthe pulp chamber.

As well as the problems associated with theprimary dentition, endodontic treatment of permanent teeth in children may also presentdifficulties due to the incomplete root develop-ment and associated open apices.

BALANCED EXTRACTIONSPrimary teeth with pulpal exposure or pathologymust always be treated, either by root canal treat-ment or by extraction. The maintenance of archlength is important for good masticatory function and the future eruption of the permanent dentition with optimal developmentof the occlusion. Whilst it is preferable to

ENDODONTICS1. The modern concept of

root canal treatment2. Diagnosis and treatment

planning3. Treatment of endodontic

emergencies4. Morphology of the root

canal system5. Basic instruments and

materials for root canaltreatment

6. Rubber dam and accesscavities

7. Preparing the root canal8. Filling the root canal

system9. Calcium hydroxide, root

resorption, endo-periolesions

10. Endodontic treatmentfor children

11. Surgical endodontics12. Endodontic problems

Fig. 1 An extracted deciduous molar showing therelatively large pulp chamber and root canals.

Fig. 2 A radiograph of a grossly carious lower secondprimary molar showing interadicular bone loss.

PRACTICE

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BRITISH DENTAL JOURNAL VOLUME 198 NO. 1 JANUARY 8 2005 9

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conserve a tooth rather than carry out an extrac-tion, if this does become necessary, balancedextractions should always be kept in mind. Abalanced extraction is the removal of a toothfrom the opposite side of the same arch. A com-pensating extraction, removing a tooth from theopposing arch to the enforced extraction is moredifficult to justify.1 Balanced extractions arerarely justified for primary incisors. The loss of aprimary canine, however, may have a significanteffect on the arch and balanced extractionsshould always be considered. When a primarymolar has to be extracted it may be preferable toprevent drifting with a space maintainer thancarry out balanced extractions.

Extractions should be avoided wherever pos-sible in certain groups of children; ie those withbleeding disorders, or medical conditions suchas diabetes where general anaesthesia is contra-indicated. Primary teeth should also be retainedwhere a radiograph reveals the lack of a perma-nent successor, as in Figure 3, where the patientmay find pulp therapy less stressful than extrac-tion, and in an already crowded dentition wheretooth loss would lead to even further crowdingof the permanent teeth.

ENDODONTIC TREATMENT OF PRIMARYTEETHEndodontic treatment may be indicated far earli-er when treating the primary dentition than inpermanent teeth. Obviously, treatment is indicat-ed when a patient presents with a pulpal necrosis,or symptoms of pulpitis. However, the distinctionof reversible or irreversible pulpitis applied to thepermanent teeth is not so relevant in the primaryteeth; any sign or symptom of pulpitis indicatesthe need for pulp therapy. Current research andpractice also suggests that pulp therapy will benecessary when a radiograph shows a cariouslesion extending more than halfway through thedentine, or where the carious process has led tothe loss of the marginal ridge.

However, there are important assessments tobe made as to the patient’s suitability forendodontic treatment. The general health of thepatient should be checked to ensure that thereare no contra-indications to endodontic therapy,

such as those with congenital heart disease, orpatients who are immunocompromised. The atti-tude of the parent to treatment and the child’sability to cooperate during the more lengthyprocedures require careful evaluation. The over-all dental health of the child, with particular ref-erence to the caries experience, must be takeninto account when making a treatment plan. In apoorly cared for dentition requiring multipletreatments, the complex conservation of onetooth in the presence of a number of comparableteeth of doubtful prognosis is poor paediatricdentistry and should be avoided. In addition,root canal treatment should be avoided in gross-ly decayed teeth which may be unrestorableeven after pulp therapy; in teeth where caries haspenetrated the floor of the pulp chamber; inteeth with advanced root resorption, or thoseclose to exfoliation.

An additional problem is the close relation-ship of the roots of the primary teeth to thedeveloping permanent successor. During exfoli-ation, the roots of the former resorb, necessitat-ing the use of a resorbable paste in endodontictreatment. It is also important to remember thattrauma to, or infection of, a primary tooth, mayresult in damage to the permanent tooth. Thismay vary from enamel hypomineralisation andhypoplasia to, more rarely, the delayed orarrested development of the tooth germ (Fig. 4).

DiagnosisThe reaction of pulp tissue in primary teeth todeep caries differs from that seen in the perma-nent dentition and is characterised by the rapidspread of inflammatory changes throughout thecoronal portion of the tooth. These pathologicalchanges become irreversible and, if left untreat-ed, will involve the radicular tissue. There maybe few, if any, clinical symptoms in the earlystages to indicate the extent of tissue damage.Pain may only occur after involvement of theperiradicular tissues in the spread of infection.

Children are often unable to give accuratedetails of their symptoms, and the responses toclinical tests may be unreliable. Difficulties arefrequently experienced in ascertaining thecondition of the pulp from clinical findings.

PRACTICE

Fig. 3 A dentalpanoramic tomographtaken as part of theassessment forextraction of deciduousmolars, reveals theabsence of permanentlower second premolars.

Fig. 4 Enamel hypoplasia of an upper permanent incisorfollowing infection of the primary predecessor.

10 BRITISH DENTAL JOURNAL VOLUME 198 NO. 1 JANUARY 8 2005


Radiographs, which are essential prior to thecommencement of treatment, may give littleinformation of early pathological changes.

Before commencing treatmentThe majority of the following restorative proce-dures will require adequate local anaesthesia. In accordance with the biological principlesestablished throughout this text, adequate isola-tion will also be necessary to prevent salivarycontamination. A rubber dam should be placed,and isolation completed with cotton wool rollsand saliva ejector as seen in Figure 5.

Indirect pulp cappingThe aim of this treatment is to maintain thevitality of the pulp in a deep carious lesion,when there is no direct pulpal involvement. Allthe carious dentine must be removed, and a thinlayer of sound, non-carious dentine mustremain. A lining of setting calcium hydroxide is placed, which stimulates the formation ofsecondary dentine. The tooth is restored overthe dressing with a permanent restorativematerial.

It has been suggested that other medicamentsmay be used for indirect pulp caps, for exampleantibiotic pastes and anti-inflammatory drugs,but although some success has been reported,pulp necrosis and abscess formation often resultwithout symptoms. As with the permanent den-tition, research is presently focussing on the useof adhesive materials and bonding agents forindirect pulp capping. The long-term results ofthese long-term clinical trials are awaited.

It should be noted that one technique for indi-rect pulp capping, which was described in thepast, is no longer recommended. This was wheredeep caries was carefully excavated, avoidingpulpal exposure, and the deeper layers of soft-ened dentine dressed with a calcium hydroxide-containing cement and a long-term temporarydressing. After a period of 6–8 weeks the tooth,which should have been symptomless, wasreopened, and the arrested carious lesion exam-ined. The success of this treatment was found tobe less predictable and symptoms frequentlydeveloped. It is now recommended that all cariesbe removed, and if a pulpal exposure is foundthen either a direct pulp cap or a form of pulpo-tomy is used.

Direct pulp cappingThis treatment is only recommended when asmall traumatic exposure occurs, during cavitypreparation of a vital non-infected pulp.2 A cal-cium hydroxide dressing is placed directly overthe pulp, followed by a lining and restoration,and the whole technique is carried out usinglocal anaesthesia and with adequate isolationfrom salivary contamination. It has been sug-gested that the high cellular content of primarypulp tissue may be responsible for the failure ofdirect pulp capping in primary teeth.3 Undiffer-entiated mesenchymal cells may differentiateinto osteoclastic cells in response to either thecaries or direct pulp capping which leads to inter-nal resorption. It is also suggested that exposureson axial walls have a poor prognosis as the pulpcoronal to the exposure may be deprived of itsblood supply and undergo necrosis.

Vital pulpotomy techniquesThese techniques involve the removal ofinflamed coronal pulp tissue and the applicationof a dressing to the radicular pulp in an attemptto either promote healing of, or fix, the upperportions, and to preserve the vitality of the apicaltissue. Because of the difficulties involved indiagnosing the condition of the pulp tissue histo-logically before the commencement of treatment,careful assessment must be made at each stage ofthe procedure. Whenever the haemorrhage fromthe radicular pulp stumps is profuse and uncon-trolled, the assumption is made that the inflam-matory process has extended into the radiculartissue, and the therapy modified accordingly.There are three pulpotomy techniques.

Vital formocresol pulpotomyThe treatment is carried out using local anaesthe-sia and adequate isolation. Following cavitypreparation in the normal manner, the deep cariesis removed and the coronal pulp chamber opened,such that there is no overhanging dentine inhibit-ing the complete removal of the pulp tissue. Thecoronal tissue is removed using a large excavatoror sterile rosehead bur. If a high-speed diamondbur is used it should be cooled with sterile wateror saline. Sterile cotton wool is applied to theradicular pulp tissue to achieve haemostasis. Asmall pledget of cotton wool is dipped in a 1:5dilution of Buckley’s formocresol (Table 1) and

PRACTICE

Fig, 5 A deciduous molar with a deepcarious lesion has been isolated priorto commencing endodontic therapy.



squeezed to remove excess liquid. It is placed overthe radicular pulp stump for 5 minutes in order tofix the inflamed tissue and bacteria and thusallow healing of the unaffected pulp. If the haem-orrhage has completely stopped, a layer of zincoxide–eugenol or glass-ionomer cement isapplied, and the tooth restored, preferably with apreformed stainless steel crown to prevent subse-quent fracture of the weakened tooth (Fig. 6).

Other materials have been considered as analternative to formocresol.4 Concerns about thesafety of formocresol led to investigations ofpulpotomies employing a 2% glutaraldehydesolution as an alternative dressing, but researchhas shown a lower clinical success rate than withformocresol. Concern about hypersensitivity toand handling of glutaraldehyde have largely ledto its abandonment as a treatment alternative.

Recent work by Waterhouse et al. has shownthat very favourable results have been achievedwith calcium hydroxide when it has beenapplied in carefully controlled circumstances.5

Following haemostasis, calcium hydroxide pow-der was delivered to the pulp chamber using asmall, sterile, endodontic amalgam carrier. Thepowder is condensed over the pulp stumps withan amalgam condensor and small pledgets ofcotton wool. Failure of this technique isexplained by the presence of an extra-pulpalclot separating the calcium hydroxide from thepulpal tissue and thus impairing healing.3

Both the calcium content and alkaline proper-ties of the dressing are important to achievehealing. An initial layer of necrotic tissue devel-ops, which becomes associated with an inflam-matory reaction. Subsequently, a matrix formsand mineralises to become a hard tissue barrierof dentine-like material.

Devitalisation pulpotomyThis is a two-stage procedure, used when localanaesthesia cannot be obtained to permit extir-pation of the pulp, or when haemorrhage isuncontrolled before or following the applicationof formocresol. This technique mummifies andfixes the coronal pulp tissue, whilst the majorpart of the radicular pulp remains vital, but itcarries a lower success rate.6

If the tooth is not anaesthetised, cavity prepa-ration is carried out as far as possible and accessis gained to the pulpal exposure. A small amountof paraformaldehyde devitalising paste (Table 2)on a pledget of cotton wool is applied to theexposed pulp tissue. Formaldehyde vapour liber-ated from the dressing permeates through thepulpal space, producing fixation of the tissues. Asoft layer of zinc oxide–eugenol temporarydressing is then placed, without applying pres-sure, to seal the medicament in position. Thechild and parent must be warned of possible dis-comfort, for which analgesics are recommended.After one to two weeks the tooth is checked forsigns and symptoms. The devitalised coronalpulp may now be removed, without the need forlocal anaesthesia. A hard setting layer of zincoxide–eugenol, which may be mixed withformocresol, is then placed over the radicularstumps and the tooth restored. If some vital tissueremains in the coronal pulp chamber, a furtherdressing of paraformaldehyde paste is required.

Non-vital pulpotomyThis technique has been advocated where there isirreversible change in the radicular pulp, or wherethe pulp is completely non-vital, but wherepulpectomy and root canal treatment is consid-ered impractical. The little clinical evidence

PRACTICE

Fig. 6 Stainless steelcrowns make idealrestorations forcompromiseddeciduous molars.

Table 1 Buckley’s formocresol

Tricresol 35%

Formaldehyde 19%

Glycerol 15%

Water 31%

Table 2 Paraformaldehyde devitalising paste

Paraformaldehyde 1.00 g

Carbowax 1500 1.30 g

Lignocaine 0.06 g

Propylene glycol 0.5 ml

Carmine 10 mg



PRACTICE

available suggests a limited prognosis of approxi-mately 50%. At the first visit the necrotic pulpcontents are removed as before, and, using smallexcavators, as much as possible of the radiculartissue. Beechwood creosote solution (Table 3) on acotton pledget is sealed into the cavity with a zincoxide–eugenol dressing.

One to two weeks later the tooth is checked forsigns and symptoms. If there is evidence ofinfection (sinus, pain, swelling or mobility) afurther beechwood creosote dressing should beplaced. If, however, symptoms have resolved, thetooth may be restored as with the previouspulpotomy techniques.

PulpectomyPulpectomy is indicated where the pulp is eithernon-vital or irreversibly inflamed. Although thetechnique is often considered difficult becauseof the complexity of the root canals in primarymolars, clinical studies have shown a reasonableprognosis.7 The cavity preparation and removalof the necrotic coronal pulp is carried out as pre-viously described. If the radicular pulp is necrot-ic, a two-stage procedure is required, but if it isfound to be irreversibly inflamed a one-stagetechnique may be undertaken.

One-stage techniqueThe root canals are identified and instrumented tothe working length estimated from a pre-operativeradiograph. After drying the canals with paperpoints, formocresol is applied for up to 5 minutes.The root canals are then filled with a thin mix ofzinc oxide–eugenol, using a rotary paste filler, andthe restoration of the tooth is completed.

Two-stage techniqueHere the root canals are again cleaned, shapedand irrigated to remove all necrotic debris. Apledget of cotton wool moistened with eitherformocresol or beechwood creosote is sealed inthe pulp chamber with a rigid zinc oxide–eugenol dressing for one week. At the subsequentvisit the tooth should be symptom-free, firm,without a discharging sinus. (If not, a secondapplication of beechwood creosote is required.) Ifthe tooth is found to be symptomless, a dressingof zinc oxide–eugenol, with or without the addi-tion of formocresol, is packed into the base of thechamber and the tooth finally restored.

The preceding techniques are reviewed in theUK National Guidelines.8

ReviewFollowing any form of endodontic treatment,regular clinical and radiographic reviews mustbe made of the tooth involved and its successor.If rarefaction of the bone in the furcation area isseen, further pulpectomy may be possible, butextraction is probably indicated. Radiographsshould also be checked for evidence of internalresorption, which may occur in limited areas informocresol pulpotomies, but may be moreextensive following the use of calcium hydrox-ide. It may progress to cause perforation of the

root. Inflammatory follicular cysts9 may devel-op, which necessitate the removal of the primarytooth and marsupialisation of the cyst to allowthe permanent tooth to erupt.

PERMANENT DENTITIONImmature permanent incisorsAlthough one in five children will suffer traumato their developing permanent incisors, onlyabout 6% of these will subsequently becomenon-vital and require endodontic treatment. Thecorrect initial diagnosis of such traumatisedteeth, based on signs and symptoms, radi-ographic examination and sensibility testing, istherefore very important. Laser Doppler flowme-try has shown that traumatised immature teethwith open apices may have a vital pulp even inthe absence of a response to conventional sensi-bility testing. If there is any uncertainty aboutthe vitality of the pulp, root canal treatmentshould be deferred and the tooth kept underregular review.

If, however, endodontic treatment of animmature permanent tooth with an open apex isindicated, a root-end closure technique is neces-sary to form a calcific barrier against which theobturation may eventually be compacted with-out extruding material into the periradiculartissues (Fig. 7).

The tooth should be isolated with rubber dam,and the pulp chamber accessed. Local anaesthe-sia is usually given as some vital tissue may stillbe encountered during pulp extirpation. Insevere cases an intracanal steroid dressing, suchas Ledermix, may be required for one week.Canal preparation is carried out with files toapproximately 1–2 mm short of the workinglength, estimated from the pre-operative radi-ograph and confirmed during treatment. Copi-ous irrigation with a sodium hypochlorite solu-tion is necessary to remove all necrotic debris.The root canal should be dried with paper points,and then filled to the apex with calcium hydrox-ide paste, compressed with large paper pointsand/or cotton pledgets. The access cavity shouldbe sealed with a long-term temporary dressing,such as glass-ionomer cement.

After one month, the dressing is carefullyremoved with copious irrigation, and the driedcanal refilled with calcium hydroxide paste.After a further three to six months the tooth isopened again and a large paper point used atworking length to feel for a calcific barrier. Thepaper point is gently inserted into the clean, drycanal. At the estimated working length either thepoint will remain dry, tap against a hard barrier,

Table 3 Beechwood creosote

0-Methoxy phenol (Guaicol) 47%

P-Methoxy phenol 26%

2-Methoxy, 4 methyl phenol (Cresol) 13%

M-Methoxy phenol 7%

Other 7%



PRACTICE

with no sensation to the patient indicating clo-sure, or will press against soft granulation tissuewhich the patient will feel. The average timetaken for closure is 6 months.

If no barrier is detected, the calcium hydroxideis replaced. If the open apex is found to be completely closed, the canal may be obturatedwith gutta-percha and sealer. Closure of an openapex may be anticipated in over 90% of casestreated by this technique, with a 4-year progno-sis of 85%.10 Obturation may then be completedby one of several methods. Conventional coldlateral compaction may be used, perhaps invert-ing a large gutta-percha point to obtain a goodapical tug-back. A custom gutta-percha pointmay be made by rolling several GP pointstogether after softening in solvent or gentleheat, and repeated fitting to the canal, carefullymarking the orientation at insertion. However,injectable thermo-plasticised gutta-percha maybe the most suitable obturation medium.

First permanent molarThe first permanent molar may, soon after erup-tion, show extensive caries, sometimes associat-ed with hypoplasia. Consideration must be givento the age of the patient and the dental develop-ment, the occlusion and possible need for ortho-dontic treatment, as well as the long-termrestorative prognosis of the tooth and thepatient’s ability to tolerate involved treatmentover a long period. Where necessary, plannedextractions should be considered. The primaryaim of conservation is to ensure that root growthcontinues with completion of apical formation,so that definitive endodontic treatment, ifrequired, may be carried out at a later stage.

The vitality of the tooth must be assessed andradiographs should be available, showing theextent of carious involvement and the state ofthe periapical tissues. It is essential that a localanaesthetic is administered and salivary control

achieved by adequate isolation. Caries should beexcavated and the tooth treated in accordancewith conventional protocols. If a small exposureof a vital tooth occurs, either accidentally duringcavity preparation or because of caries, and thesurrounding tissue is healthy, a direct pulp capwith calcium hydroxide cement may be applied.A lining of glass-ionomer cement is then placedto seal the dentine tubules prior to the definitiverestoration. If amalgam is used, a dentine bond-ing system should be considered to ensure complete sealing of the restoration.

If the exposure is large and the vitality of theradicular pulp is to be maintained to allow forroot development, a pulpotomy may be carriedout. Following the opening of the coronal pulpchamber and the removal of the pulp tissue, thearea is irrigated and dried. Haemostasis of theradicular pulp should be observed prior to theapplication of calcium hydroxide cement orpaste, and the provision of a permanent restora-tion. A calcific barrier should develop adjacentto the dressing, and root development continuein the presence of healthy pulp tissue.

If the pulp of a young, permanent molar isfound to be non-vital, endodontic treatmentshould be undertaken only after careful assess-ment of the developing occlusion, the conditionof the comparable teeth, the patient’s ability tocooperate and the long-term prognosis of thetooth. If pulpal necrosis occurs prior to the com-plete development of the apex, the objective oftreatment, as described earlier, is to encouragefurther deposition of calcified tissue in the apicalregion. Thorough preparation of the root canalsis carried out, avoiding damage to the apical tis-sues and cells of Hertwig’s root sheath. Calciumhydroxide is then applied as previouslydescribed. Definitive endodontic treatment iscarried out when an apical barrier has formedand the tooth is then permanently restored. Ifsymptoms arise in fully developed, young,

Fig. 7 a) An immature tooth with anon-vital pulp has been filled withcalcium hydroxide b).

a b



PRACTICE

permanent teeth, conventional orthograde root-filling with gutta-percha and sealer is indicated.

Avulsed permanent teethIn the emergency management of an avulsedpermanent tooth, time is of the essence. Thelong-term prognosis begins to deteriorate afteronly 15 minutes.11 Most cases initially presentwith a telephone call. Where possible, re-implantation should be immediate, followingrinsing if necessary in either milk (preferably) ortap water. The tooth should be held in place bybiting gently on a soft cloth until splinting ispossible by the dentist. If the person attendingthe accident is not prepared to re-implant thetooth, it should be stored in milk, normal salineor saliva (in the buccal sulcus) during the journeyto the dental surgery.

Avoiding unnecessary delay, and keeping thetooth in the transport solution to prevent dryingof the periodontal fibres, a thorough medical,dental and accident history should be taken andrecorded. Local anaesthesia may be necessary topermit manipulation of the alveolar bone, and toenable gentle syringing of the socket with salineto remove any blood clot. The tooth, handledonly by the crown, should be carefully insertedinto the socket. Root canal treatment should NOTbe commenced before re-implantation.

A non-rigid splint should be applied for 7–10days, using acid-etched resin with a soft archwire. The patient should be advised to avoid bit-ing on the splinted tooth, take a soft diet, andmaintain good oral hygiene with careful brush-ing and a chlorhexidine mouth-rinse. Systemicantibiotics may be indicated for medically com-promised patients. The patient’s tetanus statusmust be checked and a booster given by a med-ical practitioner if necessary. A review appoint-ment should be made in two days to verify thesplint, and modify it if necessary.

In very young patients where the tooth has awide-open apex and was out of the mouth foronly a short period there is a possibility of re-vascularisation of the pulp. The tooth should bekept under almost weekly review, and if anyclinical signs of non-vitality develop, such astenderness, discoloration, swelling or sinus for-mation, endodontic treatment should be com-menced immediately. Endodontic treatmentshould be commenced on all other avulsed teethwhilst the splint is in place. A long-term calciumhydroxide dressing should be sealed in place

with a glass-ionomer restoration for at least 6 months prior to verification of an apical barrierand obturation as described earlier.

Replanted teeth should be regularly reviewedfor at least 2–3 years, checking for inflammatoryresorption, replacement resorption, ankylosis,infra-occlusion and discoloration. The adjacentteeth should also be reviewed. Resorption maycommence within weeks of the injury.

Finally, it should be realised that there are somesituations where replantation is not appropriate.For example:• If the patient has other serious injuries,

which should be given priority. • If the patient has an at-risk medical history.• Where the extra-oral time is very prolonged,

the prognosis is very poor, particularly inteeth with short roots and wide apices.

• Primary teeth should not be replanted due tothe possibility of damage to the permanentreplacement.

Figures 1, 2, 3, 5, 6 and 7 have been reproduced by kindpermission of Dr M-T Hosey, Children’s Department,Glasgow University. Figure 4 is reproduced by kind permission of Professor R RWelbury.

1. BSPD and IAPD. UK national guidelines in paediatricdentistry. Int J Paediatr Dent 2002; 12: 151–153.

2. Kopel H M. Considerations for the direct pulp cappingprocedure in primary teeth: A review of the literature.Paediatr Dent 1992; 59: 141–149.

3. Gould A, Johnstone S, Smith P. Pulp Therapytechniques for the deciduous dentition. (CompactDisk) London: King’s College, 1999.

4. Waterhouse P J. Formocresol and alternative primarymolar pulpotomy medicaments: a review. Endod DentTraumatol 1991; 11: 157–162.

5. Waterhouse P J, Nunn J H, Whitworth J M. Aninvestigation of the relative efficacy of Buckley’sFormocresol and Calcium Hydroxide in primarymolar vital pulp therapy. Br Dent J 2000; 188: 32–36.

6. Coll J A, Sadrian R. Predicting pulpotomy successand its relationship to exfoliation and succedanesusdentition. Paediatr Dent 1996; 18: 57–63.

7. Barr E S, Flaitz C M, Hicks M J. A retrospectiveradiographic evaluation of primary molarpulpectomies. Paediatr Dent 2000; 13: 4–9.

8. Llewelyn D R. UK national guidelines in paediatricdentistry. Int J Paediatr Dent 2000; 10: 248–252.

9. Shaw W, Smith D M, Hill F J. Inflammatory follicularcysts. J Dent Child 1980; 47: 97–101.

10. Mackie I C, Worthington H V, Hill F J. A follow upstudy of incisor teeth which have been treated byapical closure and root filling. Br Dent J 1993; 175:99–101.

11. Andersson L, Bodin I. Avulsed human teeth replantedwithin 15 minutes — a long term clinical follow-upstudy. Endod Dent Traumatol 1990; 6: 37–42.



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