Indirect Pulp Capping and Primary Teeth: Is the Primary Tooth Pulpotomy Out of Date?

Meghan Sullivan Walsh September 27, 2010 Department of Pediatric Dentistry/LMC -Providence Literature Review

Article Title:

Indirect Pulp Capping and Primary Teeth: Is the Primary Tooth Pulpotomy Out of Date?

Author:

James A. Coll, DMD, MS

Journal:

Pediatric Dentistry

Volume (number), Year, Page #’s:

V 30 No 3, May/June 08 Pages 230-235

Major topic:

Success and comparison of Indirect Pulp Therapy (IPT) versus Pulpotomy

Overview of method of research:

Comparison and review of previous studies

.

Findings:

The AAPD guidelines report two options for maintaining the vitality of a primary molar where caries are approaching the pulp. This articles discusses and compares the success rate, risks and benefits of performing Indirect Pulp Therapy or IPT vs a Pulpotomy. The indication for IPT or a pulpotomy are identical. These primary teeth are vital, with reversible pulpitis and a normal pulp when judged clinically and radiographically. The difference occurs when the pulp is exposed through caries removal. In these cases a pulpotomy would also be an appropriate method where as the IPT would avoid a carious pulp exposure instead leaving decay, placing a medicament and a temporary filling to allow for repair prior to a final restoration. Studies have shown that when no pulp exposure has occurred from caries the pulp’s capacity to repair is excellent. The ideal measurement and success of IPT is found to be when the carious lesion is 1 mm or more away from the pulp. This method of IPT is a two step process. At the first appointment the tooth is made caries free leaving a moist, soft dentin over the pulp with calcium hydroxide and a temporary filling. 6-12 months later the lesion is reentered, all the caries are removed, and a final filling is placed. In one study using this method no pulp exposures were performed. (This study however was performed on adult teeth.) Studies also have shown that pulpotomies performed on questionable chronic pulpitis or necrosis show a 30% survival rate. This author concludes that pulpotomies should therefore be used only for vital radicular pulps and non carious exposures. He also infers that pulpotomies increase the chance of displacing infected root chips into the pulp and impairing the pulp’s repair capacity. For primary teeth whose vitality is questionable the author recommends GICC or Glass Ionomer Caries Control. Removing minimal amount of decay without anesthesia with a round bur or a spoon excavator and placing Glass Ionomer for 1-3 months and waiting for signs of pulp vitality. If the tooth remains asymptomatic with no clinical signs of irreversible pulpitis, IPT or a pulpotomy can be performed. This method has shown to increase the success of the pulp therapy by 79-92% and bacterial levels in the oral cavity were shown to significantly decrease. Studies have compared pulpotomies with formocresol, MTA and ferric sulfate. While MTA has shown the best success rate (>90%), these numbers may not be accurate due to the small sample size and length of follow up for these patients. The author states that studies show IPT also shows success rates of 90% regardless of the technique, medicament, or time frame. Most practitioners are taught and perform formocresol pulpotomies even though current literature shows lower success rates. Other recent concerns of pulpotomies is the early exfoliation of these teeth, pain occasionally involved with a pulpotomy and the side effects from the medication used.

Key Points/Summary

The author concludes that carious exposures on primary teeth should not be treated with pulpotomies or direct pulp caps. Instead a pulpectomy or extraction is the method of choice due to the low success rate and failure of these teeth. For a deep exposure close to the pulp IPT or pulpotomy is recommended. Glass Ionomer is the material of choice for caries control to asses vitality of a tooth with a large carious lesion. IPT does have a high success rate when the two step caries control method is used. The author concludes that IPT has lower cost, higher success long term and better exfoliation patterns.

Assessment of Article

The was an interesting summary of current literature. Unfortunately many of these generalizations that the author is making on IPT vs pulpotomy are not equal comparisons. Several of the studies on IPT were done on low sample sizes and on permanent dentition. In addition one can assume that IPT was a treatment method over a pulpotomy when the caries were not as extensive. It is also noteworthy that current literature including the guidelines for endodontics does states that a pulpectomy is the treatment of choice at this time for deep carious lesions and pulpal exposure which the author clearly mentions but uses as a case point against pulpotomies verse IPT.