Guideline on Pulp Therapy for Primary and Young Permanent teeth

Department of Pediatric Dentistry
Resident’s Name:Murphy Program:Lutheran Medical Center - Providence
Article title: Guideline on Pulp Therapy for Primary and Young Permanent teeth
Author(s): Pulp therapy Subcommittee
Journal: Pediatric Dentistry Clinical Guidelines
Year. Volume (number). Page #’s: 2004
Major topic: Pulp therapy

Main Purpose: Describe the diagnosis of pulp pathosis and set forth the indication, objectives, and medications for pulp therapy in primary and young permanent teeth.
Overview of method of research: MEDLINE search for pulpotomy, pulpectomy, IPT, stepwise excavation, pulp therapy, pulp exposure, calcium hydroxide, formocresol, ferric sulfate, and glass ionomer.

Findings:
The primary objective of pulp therapy is to maintain the integrity and health of the teeth and the supporting tissues. Vitality is best if possible (duh), however non vital teeth can remain clinically functional. Every treatment plan, regardless of the tooth should include the patients medical history, the value of each tooth involved with regards to the child’s development, alternatives to pulp treatment, and restorability of the tooth. When all treatment options fail, bony support cannot be regained, there is not enough tooth structure left for a restoration, there is resorption, or complications, extraction should be considered.
Apexification, reimplantation, and post and cores are not indicated for primary teeth.
All pulpal therapy should be completed w/ RDI to minimize bacterial contamination of the site.

Primary Teeth
Vital Tx

Protective Base-Material placed on the pulpal surface of a prep covering exposed dentin tubules, acting as a barrier between the restorative material or cement and the pulp, sealed restoration.
Indications- Normal vital pulp, all caries removed
Objectives- Preserve vitality, promote pulp tissue healing and tertiary dentin formation, minimized micro-leakage, have no post op sensitivity.

IPT-Deep carious lesion close to the pulp is covered by a biocompatible material to stimulate healing and repair, sealed restoration.
Indications-Either normal or reversible pulpitis, deepest carious dentin is not removed to avoid exposure.
Objectives- Preserve vitality, promote pulp tissue healing, form a complete restorative seal, have no post op sensitivity, no evidence of resorption, no harm to permanent successor.

Direct Pulp Capping-Small mechanical exposure during prep or following traumatic injury to tooth is covered with Calcium Hydroxide, sealed restoration.
Indications- Normal pulp following small mechanical exposure of trauma when conditions are optimal. Direct pulp capping of carious exposed primary teeth is not indicated
Objectives- Preserve vitality, promote pulp tissue healing, form a complete restorative seal, have no post op sensitivity, no evidence of resorption, no harm to permanent successor.

Pulpotomy-Deep carious lesion adjacent to pulp is excavated, radicular pulp is left, treatment with formo, ferric, or electrocautery to preserve radicular pulp health, pulp chamber is filled, tooth sealed with restoration.
Indications-Carious pulp exposure with normal or reversible pulpitis, or after traumatic exposure.
Objectives-Maintain radicular pulp health, form a complete restorative seal, have no post op sensitivity, no evidence of resorption, no harm to permanent successor.

Non Vital Teeth
Pulpectomy- Irreversible pulpitis or necrotic pulps is removed and filled with resorbable material such as zinc oxide eugenol, restored with sealed restoration.
Indications- Irreversible pulpitis or necrotic pulps
Objectives-symptomes should resolve in 1-2 weeks, infectious process should resolve in +/- 6 months, radiographic evidence of no over/under filliing, no resoprtion, no harm to permanent successor.

Young Permanent Teeth
Vital Teeth
For Protective base, IPT see above.

Direct Pulp Capping
Same as for primary teeth except that a small carious exposure can be treated with DPC.

Partial Pulpotomy
Indications-small (<2mm) carious exposure in which enflamed tissue beneath the exposure is removed at a depth of 1-3mm, or until healthy tissue is reached. Bleeding must be controlled within 1-2 min and the site should be covered with CaOh or MTA, sealed with rest.
Objectives- Preserve vitality, promote pulp tissue healing, form a complete restorative seal, have no post op sensitivity, no evidence of resorption or canal calcification or periradicular radiolucency, tooth should continue to develop normally.

Cvek Pulpotmy
Same treatment for partial pulpotomy except it is indicated for traumatic exposures.

Apexogenesis (root formation)
Vital pulp procedure that allows the continued physiological development and formation of the roots apex by use of the treatment previously described .

Pulpectomy(Conventional RCT)
Indications- Traumatized, infected, exposed, or necrotic fully formed teeth. Entire pulpal tissue is debrided, irrigated, canal is shaped, obturation with non restorable filling material.
Objectives- symptoms should resolve in 1-2 weeks, infectious process should resolve in +/- 6 months, radiographic evidence of no over/under filling, no resoprtion, no further breakdown of periradicular tissue.

Apexification
Indications-Incompletely formed non vital tooth. Coronal and no vital tissue is removed just short of the root end, CaOh or MTA is placed. Once an apical closure is obtained RCT should be completed.
Objectives-Induce root end closure, no resoprtion, no further breakdown of periradicular tissue.

Key points/Summary:
Apexification, reimplantation, direct pulp capping of a carious pulp exposure, and post and cores are not indicated for primary teeth.
All pulpal therapy should be completed w/ RDI to minimize bacterial contamination of the site.

Assessment of Article: This article was tough to “summarize” as it is itself a summary of ALL pulpal tx. Good guideline overall. We should all know this stuff backwards and forwards.