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QUESTION: Hello,

I am wondering if it is true that there is no such thing as a pediatric endodontist? I have searched and searched, but to no avail. I have called many endodontists in my city, but all have said they only see children with their permanent teeth. My daughter is 3 years old, and slipped on a tile pool deck this past summer, injuring her top two front teeth. Just before New Years day, a bump appeared on her gum above one of the injured teeth. We've taken her to two pediatric dentists, and the prognosis is the same; one tooth has abscessed, and extraction is the solution. I find it so hard to believe that there is no way to save her baby teeth. The second dentist explained it much better than the first (who didn't explain anything), but honestly, I still feel like I just don't get it. She said something about the filler being used in the pulpotomy pushing the infection up closer to the adult teeth...so I am wondering, can the infection be drained during the procedure before the filler is put in the nerves? Is it possible to do a pulpotomy successfully on the top front baby teeth? The dentist said that even with the pulpotomy, we would likely have her in for extraction within 6 months because the infection would come back, and I guess I just don't understand why that is. If you could shed any light on this, please let me know.

ANSWER: In general, from what I have witnessed during my teaching career, pediatric dentists are very poorly trained in endodontics. I think the prevailing opinion is that the teeth can come out as they will be replaced anyway. This, of course, begs the question, "What do we do in the meantime?" Of course the child will not starve because of missing front teeth, and it this occurs when their classmates are losing their front teeth too it might not be noticeable, but a three-year old has some time to go. Those teeth are very simple inside, just basically hollow tubes. They can be very quickly cleaned out and could be filled with a paste which could be basically just zinc oxide and eugenol, that would be absorbed as the tooth is resorbed when it is time for it to go. If some problem, i.e. ankylosis occurred, and the roots were not resorbing and interfering with the eruption of the succedaneous teeth, then they could be extracted at that time. The endodontists don't want to do this because to the management problems inherent with small children, not because they can't do the treatment. So, it really should be done by the pediatric dentist. I used to have my (endo) residents go over to pedo and do the procedure with the pediatric dentistry resident handling the management issues and my resident doing the actual treatment. Still, it is not that difficult and any pediatric dentist really should be able to do it.

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QUESTION: I really appreciate your response. Is it possible to determine the likelihood of this ankylosis occurring post-procedure simply by looking at an x-ray of the abscessed tooth? The second pediatric dentist who is capable of performing the procedure (the first was not, they actually wanted to extract the teeth right then and there, "10 minutes they'll be out" they said) said that she would recommend extraction as well. She stated that if she did the procedure, my daughter would more than likely be back in for extraction within 6 months. I asked her why she doesn't think a pulpectomy would be successful on my daughter, and she said because it would be harmful to her adult teeth to push the infection up closer to them with the Fillers used during the procedure. I asked why is the infection still there if my daughter will be given a round of antibiotics? She said because of the nerve damage, white blood cells can't reach the site of the infection as they need to in order to clear the infection. I am wondering can the site be drained during the procedure? Is there any antiseptic property of the fillers used that would kill what bacteria were still present at the point of the procedure?

Answer
That is a rather complex question, and one your dentist is apparently confused about. A "pulpectomy" can mean different things to different people, but it should mean complete cleansing and shaping of the root canal in this case. The only difference between this procedure and what we would do for an adult tooth is that the filling material must be something that can be absorbed by the body as the tooth itself is resorbed during the exfoliation process. The gutta-percha we would use for an adult cannot be absorbed, so it would remain in the bone. As you correctly noted, once the cause of the infection, which is the dead material in the root canal, is removed, the infection in the bone will heal. The rest, the bit about the nerve damage and white cells not reaching the area, makes no biologic sense. Once the cause is removed, your body's immune system will send white blood cells and phagocytes to the area to get rid of the infection and it will heal up. There is no reason for her to extrude the filling material, be it calcium hydroxide based or zinc oxide and eugenol based; that is a matter of good technique. I would not use an injected paste but make a stiff paste and place it with an endo condenser. I would suggest not using MTA because I do not know of any cases like this where it has been used and I do not think it could be absorbed once set, but that is a subject for research.  

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Frederick R. Liewehr DDS, MS, FICD

Expertise

I can answer your questions about root canal therapy in general. PLEASE DO NOT ask me to diagnose your particular problems or recommend treatment as I cannot do this without examining you and seeing your x-rays.

Experience

I am a Board-certified endodontist, former university department Chairman, teach dental residents, and have a private practice.

Organizations
ADA, AAE, ICD, AAOM, FDI, AMSUS, AAOB

Publications
J of Endodontics, Endodontics and Dental Traumatology, O,O,O, Military Medicine, Medical Bulletin, J of Dental Education

Education/Credentials
DDS, MS (Oral Biology), certificate in Endodontics

Awards and Honors
Surgeon General's "A" Designator, Fellowship ICD, Order of Military Medical Merit

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