Endodontic treatment may be indicated far earlier when treating the primary dentition than in permanent teeth. Obviously, treatment is indicated when a patient presents with a pulpal necrosis, or symptoms of pulpitis. However, the distinction of reversible or irreversible pulpitis applied to the permanent teeth is not so relevant in the primary teeth; any sign or symptom of pulpitis indicates the need for pulp therapy. Current research and practice also suggests that pulp therapy will be necessary when a radiograph shows a carious lesion extending more than halfway through the dentine, or where the carious process has led to the loss of the marginal ridge.
However, there are important assessments to be made as to the patient’s suitability for endodontic treatment. The general health of the patient should be checked to ensure that there are no contra-indications to endodontic therapy, such as those with congenital heart disease, or patients
who are immunocompromised. The attitude of the parent to treatment and the child’s ability to cooperate during the more lengthy procedures require careful evaluation. The overall dental health of the child, with particular reference to the caries experience, must be taken into account when making a treatment plan. In a poorly cared for dentition requiring multiple treatments, the complex conservation of one tooth in the presence of a number of comparable teeth of doubtful prognosis is poor paediatric dentistry and should be avoided. In addition, root canal treatment should be avoided in grossly decayed teeth which may be unrestorable even after pulp therapy; in teeth where caries has penetrated the floor of the pulp chamber; in teeth with advanced root resorption, or those close to exfoliation. An additional problem is the close relationship of the roots of the primary teeth to the developing permanent successor. During exfoliation, the roots of the former resorb, necessitating the use of a resorbable paste in endodontic treatment. It is also important to remember that trauma to, or infection of, a primary tooth, may result in damage to the permanent tooth. This may vary from enamel hypomineralisation and hypoplasia to, more rarely, the delayed or arrested development of the tooth germ (Fig. 4).