Primary tooth - pain or infection
Primary tooth with pain or infection
Clinically, it is useful to divide this process into three stages, pulpitis with reversible symptoms, pulpitis with irreversible symptoms, and dental abscess/periradicular periodontitis. However, these do not refer to discrete, well separated stages of pathology, but are on a continuum of unmanaged pulpal disease from mild inflammation through to pulpal necrosis. Clinicians must use their clinical judgement to quantify the extent of the pulpal pathology and then determine the appropriate management strategy.
Pulpitis – reversible symptoms
Description: Pain is provoked by a stimulus (e.g. cold, sweet) and relieved when it is removed. The pain is intermittent and does not tend to affect the child’s sleep. The pulp is still vital and the tooth is not tender to percussion.
Aim: To remove pain and avoid the disease progressing to pulpitis with irreversible symptoms.
Place a crown using the Hall Technique or if an occlusal lesion, carry out selective caries removal, avoiding the pulp, and restore using composite, resin modified glass ionomer, compomer or glass ionomer.
- Where there are symptoms of pain that may be due to food packing or pulpitis with reversible symptoms but the diagnosis is uncertain, a temporary dressing can be placed into the cavity and the patient reviewed 3-7 days later to check symptoms. Resolution of the symptoms at review will indicate that the pulpitis was reversible and a Hall crown or suitable restoration can then be placed. If symptoms do not resolve or worsen then extraction or pulpotomy (see Pulpotomy for primary teeth) should be considered.
- Where a radiograph shows no clear separation between the carious lesion and the dental pulp (see Assessing carious lesions), it is likely that the carious lesion has encroached significantly on the dental pulp and a pulpotomy or extraction will be necessary.
If the tooth is close to exfoliation, consider applying a dressing.
Pulpitis – irreversible symptoms
Description: Pain that can occur spontaneously but if provoked by a stimulus is typically not relieved when the stimulus is removed. The pain may last for several hours and may keep the child awake at night. The pain may be dull and throbbing, worsened by heat and may be alleviated by cold. There are no signs and symptoms of infection such as sinuses or abscesses or periradicular pathology and the pulp is still vital, although inflamed. Usually the tooth is not tender to percussion.
Aim: To relieve pain.
If cooperation allows, carry out pulpotomy (see Pulpotomy for primary teeth), or extract the tooth (see Extraction).
If the child is anxious, and/or it is their first visit, gently remove gross debris from the cavity, and apply corticosteroid antibiotic paste under a temporary dressing. Ideally, if cooperation permits, open the pulp chamber under local anaesthesia and apply corticosteroid paste directly to the pulp, then place a dressing. Prescribe pain relief then carry out a pulpotomy (see Pulpotomy for primary teeth) or extract the tooth (see Extraction) at a later date.
If the child is uncooperative, refer for treatment/extraction with general anaesthesia or sedation (see Referral).
Dental abscess/periradicular periodontitis
Description: Pain, if present, may be spontaneous, will keep the child awake at night and can be easily localised by the child. The tooth will show increased mobility and will be tender to percussion. Clinical evidence of a sinus, abscess or swelling or radiographic evidence of interradicular pathology may be present.
Aim: To remove the source of infection and avoid or relieve pain.
If the child is cooperative, extract the tooth, even if the infection is asymptomatic. In exceptional circumstances if the tooth is restorable, consider a pulpectomy, which may require referral.
- In some cases, local measures to bring infection under control may be appropriate.
If the child is uncooperative or there are multiple abscessed teeth, refer to a specialist for treatment/extraction with general anaesthesia or sedation (see Referral).