The Pulp Fiction: Can You Save Your Child's Smile Without a Root Canal

The heartbreaking incident of a 3-year-old succumbing after a pulpectomy in Kerala has got many parents scared and adrift. The tragic event has raised concerns about dental care and treatment needs in children, the importance of healthy milk teeth, and the alternate treatment options when required.

Let’s first address the elephant in the room: Are root canal treatments needed at such a young age? The answer is yes, but not as often as one may think. The need for 'baby root canal treatment' depends on the extent of dental caries and infection in the surrounding tissues. A popular misconception is that baby teeth do not need much care as they will eventually fall and be replaced by permanent teeth. But contrary to this, milk teeth play a crucial role in the child's development. They guide permanent teeth into their natural position, contribute to chewing, and assist speech development and growth of jaws whilst acting as natural space maintainers for permanent teeth.

So, when is a root canal actually needed for the tiny milk teeth? “Well, the need for pulpectomy may arise in case of a long-standing untreated cavity, that becomes infected over time and eventually reaches the pulp – the soft tissue inside the hard shell of the tooth, containing nerves and blood vessels. This may eventually cause severe pain, discomfort, swelling, and inability to chew and sleep at night,” says Dr. Priya Telang, Dental Practitioner in Pune, Maharashtra.

Pulpectomy, also referred to as 'baby root canal treatment' is a procedure of removing dead infected pulp tissue from the center of the tooth. The space is then filled with soothing medicament in the tooth to help retain it for a longer duration. The procedure is time-consuming and it may need multiple appointments.

Baby teeth have thin and softer enamel layers that cause cavities to spread fast and reach pulp at a quicker pace than in adult teeth. The spread of infection and swelling is also rapid due to less dense tissues around the teeth and bone. Untreated caries may progress to advanced cavitation and pulp infection leading to :

• Intense Pain: The inflamed and infected pulp can cause throbbing pain that can interfere with eating, sleeping and general well-being.

• Swelling: The gum tissue around the tooth can become inflamed and sore, causing discomfort, bleeding and difficulty in eating. The swelling can further increase and spread to involve larger portion of jaw closer to the site.

• Abscesses: In severe cases, the infection can spread to the bone around the tooth, resulting in abscess or pus formation. This can be a serious condition requiring immediate medical attention due to infections such as Ludwig's Angina or other space infections, causing difficulty in mouth opening and breathing.

• Tooth Loss: If left untreated, advanced dental caries can eventually lead to destruction of tooth structure beyond repair and untimely tooth loss.

• Spread of Caries: Long standing untreated caries in milk teeth can spread to adjacent milk teeth and the newly erupted permanent teeth.

Anesthesia, whether local or general, is administered to alleviate the pain during the procedure and is used in most dental procedures if not all. Local anesthesia is a chair-side procedure and is administered to numb a small area at the local site. Extensive procedures may demand sedation under Nitrous oxide, also known as ‘laughing gas’, where the patient is awake, conscious, and responsive to stimulus. General anesthesia, on the other hand, is controlled loss of unconsciousness induced under the supervision of an anesthetist.

In his conversation with MedBound Times, Dr. Vinaya Kumar Kulkarni, Leading Pedodontist and Head of Department, at SMBT Dental College and Hospital, Sangamner, emphasized the importance of safety and vigilance of both medical practitioners and parents. He says that general anesthesia may be required for children who need extensive dental treatment or cannot cooperate due to young age or anxiety. Cautions that can be exercised for safety are:

• Qualified Providers: Research highlights the importance of choosing dentists or oral surgeons experienced in pediatric anesthesia. Recent guidelines emphasize that providers should be trained to handle potential complications and monitor children effectively during anesthesia.

• Risk Assessment: Pre-operative evaluations are critical to assess a child’s overall health and determine anesthesia risks. Recent studies stress the need for thorough medical histories and physical examinations before proceeding with anesthesia to minimize complications.

• Anesthesia Safety Protocols: Updated protocols aim to ensure safety, including fasting guidelines to prevent aspiration and precise dosing of anesthesia medications. Recent advancements in monitoring equipment and techniques further enhance safety during procedures.

• Post-Anesthesia Care: Studies emphasize the importance of post-operative monitoring and care instructions. Parents should follow guidelines for pain management, diet restrictions, and monitoring for any adverse reactions following anesthesia.

• Informed Decision Making: Healthcare providers should communicate the risks and benefits of anesthesia clearly to parents. Recent research underscores the importance of informed consent; ensuring parents understand potential risks and feel confident in the anesthesia plan.

While the best approach to dental caries is prevention and prompt treatment saving the caries from reaching the pulp. In the early stages of pulp infection, a dentist may recommend implementing strict oral hygiene practices and preventive measures.⁽¹⁾ However, once the infection has progressed, a pulpectomy is usually preferred, some alternatives are:

Dental Fillings: For small to medium-sized cavities, removing the decayed portion of the tooth and restoring it with a filling can restrict the cavity from progressing further.

Pulpotomy: In infections that have not entirely destroyed the pulp and in case most of the pulp is free of inflammation, partial removal of infected pulp can be done. The remaining part of the pulp is covered with a dressing and closed with a filling or crown on top.

Silver Diamine Fluoride: Also commonly known as SDF, is proven to be effective in caries inactivation and is well-accepted by children and parents. The only disadvantage is black discoloration of carious teeth.

Crowns: In some cases, a crown (cap) can be placed over the tooth after removing the carious part. Crown restricts further progress of infection and provides additional protection against chewing forces.

Extraction: As a last resort, if the tooth is severely damaged or the infection cannot be controlled, extraction might be necessary.

MedBound Times contacted Dr. Sneha Kamble, BDS, Practicing Dentist at Sangamner, Mumbai, Maharashtra. She tells us that, parents play a crucial part in maintaining oral health of children. She has been counselling the parents on 'how to save your child's smile' by creating awareness about early detection of cavities and their timely treatment through regular dental checkups and maintaining good oral hygiene practices such as:

• Effective Oral Hygiene: Brushing teeth twice a day with fluoride toothpaste and flossing daily are crucial. Fluoride helps remineralize enamel, making teeth more resistant to acid attacks from bacteria. Studies continue to reaffirm the effectiveness of fluoride in preventing cavities, especially when combined with good brushing habits.

• Balanced Diet: Limiting sugary snacks and drinks is essential. Recent research underscores that frequent exposure to sugary foods and beverages increases the risk of cavities. Instead, encourage water consumption, minimizing snacking between meals and if at all needed give snacks like fruits and vegetables (food rich in fiber), which are less likely to contribute to decay.

• Sealants and Fluoride Treatments: Dental sealants, which create a protective barrier over the chewing surfaces of molars, have shown significant effectiveness in preventing cavities. Recent studies highlight their role in reducing tooth decay by up to 80% in treated teeth. Fluoride varnish applications by dental professionals also help strengthen enamel and prevent decay.²

• Early Dental Visits: The American Academy of Pediatric Dentistry recommends children see a dentist by their first birthday or within six months of their first tooth erupting. Early dental visits allow for early detection of dental problems and implementation of preventive measures.

• Parental Education: Educating parents about the importance of oral hygiene and regular dental visits is crucial. Studies indicate that children whose parents have good oral health habits are more likely to adopt those habits themselves.

  By focusing on these preventive measures from an early age, parents can significantly reduce the risk of their child needing invasive treatments like pulpectomy.

  However, if a pulpectomy becomes necessary, it is important to understand that it is a safe and well-established procedure. When performed by a qualified dentist using proper techniques, the success rate of pulpectomy in children is very high.

References:

1. American Academy of Pediatric Dentistry (AAPD). 2024. "Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures." https://www.aapd.org/globalassets/media/policies_guidelines/bp_monitoringsedation.pdf. Accessed July 11, 2024.

2. American Academy of Pediatric Dentistry (AAPD). 2019. "The Importance of the Age One Dental Visit." https://www.aapd.org/globalassets/media/policy-center/year1visit.pdf. Accessed July 11, 2024.

By Dr. Abhilasha Manker