DCA06DT Dental Treatment of Pediatric and Adolescent Patients _ __________________________________
Periodic radiographic assessment is necessary to evaluate the continuity of root formation and apexogenesis. Some teeth restored in this fashion may remain asymptomatic and exhibit no apical pathology, while others will require conventional root canal therapy after the root apex has completed its formation. EXTRACTION Caries in deciduous and immature permanent teeth may progress to the point that the tooth is no longer restorable and must be extracted. Although deciduous teeth are designed to be shed, they maintain an important role in occlusion and phonation. Unrestorable deciduous teeth should be extracted before causing drifting of adjacent teeth or creating an obstacle to the eruption of permanent teeth. A classic example of this occurs with the premature loss of deciduous second molars. Because the maxillary and mandibular permanent first molars erupt long before the anticipated exfoliation of the deciduous second molars, which are eventually replaced by the permanent second bicuspids, the premature loss of second deciduous molars allows the permanent first molars to drift mesially and create an obstacle to the eruption of the permanent second bicuspids. A space maintainer may be necessary to prevent this occurrence. The space maintainer is cemented onto the permanent first molar and is removed after the permanent second bicuspid has erupted to a position that will prevent mesial drift. APEXIFICATION Carious lesions that are left untreated will eventually cause necrosis of the coronal and radicular pulp. Necrotic (non-vital) immature permanent teeth present a unique challenge, as the non-vital radicular pulpal tissue cannot contribute to further development of the root and apexogenesis. In these cases, an apexification procedure is used. Conventional root canal therapy cannot be completed because the root of the imma- ture permanent tooth has an open apex that cannot provide a definitive stop for obturation material. The apexification procedure is designed to create a definitive calcified stop in the apical region of the root, which would then allow gutta percha to be used to complete definitive root canal therapy. The initial appointment consists of the debridement and removal of the necrotic remnants of the pulpal tissue. A thick paste of calcium hydroxide is placed into the cleansed and debrided canal to stimulate the formation of the calcified stop in the apical region of the root. Whether calcium hydroxide is placed during the initial or second appointment, it is covered with a temporary filling material and left within the canal for approximately six months. If a calcified stop near the apical region of the tooth is confirmed by radiographs and is tactilely encountered by endodontic instruments such as files or ream- ers, conventional endodontic treatment can be completed [22]. If the stop is not encountered, the canal is retreated with calcium hydroxide paste. The complete loss of pulpal tissue in an immature permanent tooth precludes the continued
thickening and developing of the root canal walls even if the apexification technique and subsequent endodontic therapy are successful [23]. This makes the tooth more susceptible to fractures of the crown or the root. A full-coverage crown can decrease, but not eliminate, the potential for coronal fractures. Patients should be reminded to minimize pressure to treated teeth and should be instructed to wear protective mouth guards during athletic activities. Procedures such as pulpotomies of deciduous and immature permanent teeth and apexification should only be performed by clinicians who have had adequate training. Referral to a pedodontist or endodontist should be considered if the required clinical techniques are beyond the capabilities of the general practitioner. PREVENTIVE DENTISTRY FOR CHILDREN AND ADOLESCENTS Of course, the ultimate goal for each child and adolescent is avoidance of dental caries. Unfortunately, many patients in this age range have one or more carious lesions. Infants and children are dependent upon their parents/caregivers to brush and floss their teeth, to bring them to the dental office for exams and routine prophylaxis appointments, and to provide nutrition that is conducive to good oral and general health. There are general guidelines for the prevention of dental caries in children and adolescents that may be helpful for clinicians and parents/patients. Oral problems that are diagnosed early can be treated conser- vatively and inexpensively. As such, the American Academy of Pediatric Dentistry has recommended an initial dental examination as early as the first tooth eruption and no later than 12 months, which would include a caries risk assessment, oral hygiene instructions for the parent(s), and a general assess- ment of the child’s oral health [24]. SEALANTS As discussed, the use and efficacy of pit and fissure sealants can decrease the risk of caries associated with anatomical features in deciduous and permanent teeth. Parents may be unaware of this preventive option, especially if sealants were never used for their own teeth. The benefits of this approach should be discussed with the parents, but it is important that they know that pit and fissure sealants are not a substitute for good oral hygiene. Parents should also understand that the cost of pit and fissure sealants is per tooth and that insurance company reimbursement is variable.
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