Guideline on Pulp therapy for Primary and Immature Permanent Teeth

Resident: Swan
Article Title: Guideline on Pulp Therapy for Primary and Immature Permanent Teeth
Journal: Pediatric Dentistry
Volume (Number): 32(6).
Main Purpose: To aid in the diagnosis of pulp health vs. pathosis and to give indications, objectives, and interventions for pulp therapy in primary and immature permanent teeth.
Key Points: Correct pulpal therapy depends on correct diagnosis as vital or nonvital based on subjective and objective tests. From these tests we conclude if the tooth has normal pulp (symptom free and normally responsive to testing), reversible pulpitis (pulp capable of healing), irreversible pulpitits (inflamed pulp incapable of healing), or necrotic pulp. In permanent teeth, electric pulp tests and thermal tests are helpful.
Signs/symptoms of irreversible pulpitis/necrosis (non-vital therapy needed): history of spontaneous, unprovoked toothache, a sinus tract, soft tissue inflammation not resulting from gingivitis or periodontitis, excessive mobility not associated with trauma or exfoliation, furcal/apical radiolucency, internal/external resorption.
S/S of reversible pulpitis (vital therapy indicated): Provoked pain, short duration, relieved with OTC meds, by brushing, or upon the removal of stimulus.
A couple general recommendations: 1. Always perform pulp therapy with rubber dam to minimize contamination 2. X-ray of primary tooth pulpectomy should be obtained immediately following procedure. 3. Monitor posterior pulpotomies with x-rays that clearly show the interradicular area. Good bitewings can suffice.
Tx for Primary teeth:
Protective liner: thinly applied liquid applied to pulpal surface of deep cavity preparation, covering exposed dentin tubules and acting as protective barrier. Can be Calcium Hydroxide, dentin bonding agent, glass ionomer cement. Indicated in tooth with normal pulp.
Indirect pulp tx: performed in teeth w/ deep carious lesions but with no signs or symptoms of pulp degeneration. Caries surrounding pulp is left to avoid exposure, then covered with bonding agent, RMGI, CaOH2, IRM, GI. If CaOH2 is used, seal with GI or IRM to avoid microleakage. Current literature shows inconclusive evidence as to whether or not the tooth needs to be re-entered. IDPC has higher success rate than pulpotomy in long term studies and allows for normal exfoliation. Use for pulps that are normal or show reversible pulpitis.
Direct Pulp Cap: Place MTA or CaOH2 in contact with exposed pulp tissue after pinpoint mechanical exposure during cavity prep or following trauma. Then restore with material that provides good seal. Direct pulp capping of carious exposures is not recommended.
Pulpotomy: Performed in primary tooth with extensive caries but no radicular pathology when caries removal results in exposure. Coronal pulp amputated and remaining vital radicular tissue is treated with formocresol, ferric sulfate, or MTA. Most effective restoration is SSC. Amalgam or composite can be used if there’s enough tooth left and the remaining life span is 2 yrs or less. Do not perform pulpotomy if tooth shows continued suppuration, necrosis or excessive hemorrhage that can’t be controlled with damp cotton pellet after several minutes. If internal root resorption after pulpotomy can be be self-limiting and stable. Remove tooth is resorption casues loss of supportive bone or clinical signs of infection.
Nonvital tx for primary teeth with irreversible pulpitis or necrosis:
Pulpectomy: Tx for pulp tissue that has above conditions. Canals are debrided and shaped with hand file or rotary files. Irrigate with Sodium hypochlorite. Dry canals and fill with resorbable zinc oxide/eugenol or iodoform/CaOH2 mix (Vitapex). Restore tooth to prevent microleakage.
Treatment for young permanent teeth:
Protective liner: Same as for primary teeth
IDPC: Same as for primary teeth
Partial pulpotomy for carious exposures: Inflamed pulp tissue beneath exposure is removed to depth of 1 to 3 mm to reach healthy pulp tissue. Make sure bleeding is controlled with pressure/hypochlorite before covering with MTA or CaOH2. Layer with RMGI, then restore to prevent microleakage. Indicated in young permanent tooth with carious exposure in which pulpal bleeding is controlled within several minutes. Tooth must be vital, with healthy pulp or reversible pulptitis.
PP for traumatic exposures (Cvek): Same as above. Indicated for vital, traumatically-exposed young permanent tooth, especially one with incompletely formed apex.
Apexogenesis: formation of the apex in vital, young, permanent teeth can be accomplished by using the appropriate vital therapy described above.
Nonvital pulp treatment:
Pulpectomy (conventional endo tx)
Apexification: method of inducing root end closure of incompletely formed nonvital perm tooth. Remove coronal and nonvital radicular pulp and place CaOH2 for 2-4 weeks to disinfect the canal space. Root end closure is accomplished with an apical barrier like MTA. When complete closure can’t be accomplished with MTA, an absorbable collagen wound dressing (CollaCote) can be placed to form a matrix for the MTA at the root end. Gutta percha used to fill remaining canal space.