PULP THERAPY FOR CHILDREN

Pediatric Dentistry I
Jilliane J. Lee, DMD

goals of PULP THERAPY

• Successful treatment of the cariously involved pulp, allowing the tooth to remain in the mouth
in a non-pathologic state
• Maintenance of arch length and tooth space
• Restoration of comfort with ability to chew
• Prevention of speech abnormalities and abnormal habits

Clinical Assessment and General Consideration

Diagnosis of Pulpal Status

O – Onset
L – Location
D – Duration
Ch – Characteristics of Pain
A – Aggravating/Alleviating Factors
R – Radiation
T – Time
S – Severity

Clinical Assessment and General Consideration

Clinical Signs and Symptoms
• Presence of abscess or draining fistula
• Abnormal tooth mobility
• Sensitivity to percussion or pressure

Clinical Assessment and General Consideration

Other Clinical Signs
• Coronal discoloration
• Clinical mobility
• Marginal ridge fracture in a primary tooth
• Fracture of the occlusal triangular ridges or carious undermining the cusps

**External appearance of carious lesion can be misleading. Additional examination is essential.

Clinical Assessment and General Consideration

• Radiographic Interpretation
• Pulp Sensibility Tests
o Limited value for children
o In the immature permanent tooth, raised response thresholds to electrical stimuli
• Physical Condition of the Patient
o Chronically ill children should not be subjected to the possibility of an acute infection
resulting from failed pulp therapy
 VITAL PULP THERAPY for primary and young permanent teeth

A. INDIRECT PULP CAPPING

• Rest treatment
• Deep carious lesion encroaching on, but not actually into, the pulp
• Reserved for permanent teeth (young permanent) only
• Stimulate the tooth to assist its own recovery from the near pulpal exposure
• ZOE or calcium hydroxide is placed over the carious dentin

Pain History
• No extremes
• May be associated with eating
• Sometimes dull

Clinical Examination
• No gingival pathologic conditions
• No mobility
• Large carious lesion

Objectives:
• Reversal of bacterial invasion
• Treatment of carious dentin
• Maintenance of normal healthy pulp

Radiographic Examination
• Probable pulpal exposure
• Normal periapical tissues

Justification
• Reduction of hyperemia in pulp
• Remineralization of carious or precarious dentin
• Reduction of anaerobic bacteria
• Formation of reparative dentin
• Vital pulp maintenance
• Continued normal root closure

B. Direct pulp capping

• Placement of calcium hydroxide on a small, mechanically induced pulpal exposure
• Should be limited to permanent teeth
• Higher rate of failure for primary teeth

 Frank et al, 1978 – “ The direct pulp cap is the least desirable course of treatment,” with a poor
prognosis, and it should rarely be used. Thus, DPC on primary teeth, whether mechanical or carious
exposure, is contraindicated.
C. Pulpotomy
• Removal of the coronal portion of the pulp for treating both primary and permanent teeth with
carious pulp exposure
• Remove inflamed coronal portion of the pulp, allow pulpal tissue in the root canal to remain
vital, and maintain the tooth in the dental arch

candidates for vital pulp therapy

• Tooth with deep caries without pulp exposure
• Carious or traumatic pulp exposure
• Transitory thermal and/or chemical stimulated pain
• Physiologic mobility
• Normal soft tissue
• No percussion sensitivity
• Intact continuous ligament space
• Intact periapical and/or furcation bone
• Less than 1/3 physiologic root resorption
• Tooth is restorable

Treatment Objectives
• Eradicate potential for infection
• Maintain tooth in a quiescent state
• Preserve space for underlying permanent tooth
• Retain primary tooth, if permanent is congenitally absent

Indications – Clinical Examination

• No gingival pathologic condition or evidence of a chronic sinus tract
• No extreme mobility of the tooth
• Deep carious lesion

Indications – Radiographic Examination

• Probable carious exposure
• Normal interradicular periapical tissues
• Normal root development
• No internal or external root resorption

Failure – Indications
• Increased mobility, fistula
• Premature exfoliation
• Radiographic evidence of interradicular or periapical radiolucency
• Internal or external resorption

Failure – Cause
• Poor diagnosis and treatment selection
Pulpotomy - procedure
1. Use local anesthesia – profound anesthesia
2. Apply a rubber dam isolation
3. Gain access to the pulp chamber by preparing a Class I cavity preparation. Remove all
overhanging enamel.
4. Remove all carious dentin before exposing pulp horns using sterile slow-speed round burs (
No. 4 or 8)
5. Visualize pulp horns beneath the pulpal floor, with the use of slow- or high-speed bur,
connect the pulp horns
6. Excise the pulpal tissue to the orifices of the root canal with the use of a large, SHARP spoon
excavator. Gently wash out debris with the water syringe.
7. After completion of amputation, evaluate and control hemorrhage.
8. Place a sterile cotton pellet moistened (not saturated) with formocresol over the pulp
stump. Place a dry pellet over the first pellet to maintain maximum contact of the
formocresol with pulpal tissue. Apply for 5 minutes.
9. Fill the chamber with zinc oxide eugenol
10. Prepare the tooth with stainless steel crown.

Pulpotomy – medicaments

1. FORMOCRESOL
• Full-strength (Buckley’s FC) – 19% formaldehyde, 35% cresol in glycerin and water
• Dilute FC (1/5 concentration = 1part FC:4 parts vehicle (3parts glycerin:1part water)
• Bactericidal
• No dentinal bridging, but calcific changes evident
• Succedaneous tooth damage a small risk
• Exfoliation accelerated
• Cellular toxicity
• Immune sensitization risk
• Humoral and cell-mediated response – controversial
• Mutagenic and carcinogenic potential - controversial

2. Ferric Sulfate
• 15.5% in aqueous base, pH=1
• Denatures protein and forms ferric ion complex that occludes cut blood vessels
• Shorter application time than FC (10-15 seconds)
• Self-limiting internal resorption reported

3. Mineral Trioxide Aggregate (MTA)

• Dental cement with discrete crystals and amorphous structure, pH=12.5
• Pulp canal obliteration common
• Promising clinical results
D. Pulpectomy
• Complete removal of necrotic tissue from the root canals and coronal portion of non-vital
primary teeth to maintain a tooth in the dental arch
• Aimed at reduction of bacteria in the contaminated pulp canals

INDICATIONS:
• Traumatized primary incisors with resultant pathologic conditions
• Primary second molars
• Permanent immature teeth with immature roots
• No evidence of pathologic conditions, with root resorption not more than 2/3 or ¾ completed

JUSTIFICATION:
• Removal of diseased pulp tissue
• Space management

CONTRAINDICATIONS:
• Non-restorable tooth
• Pathologic condition extending to the developing tooth bud
• Less than 2/3 of the primary root structure plus, internal or external resorption
• Internal resorption of the pulp chamber and root canals
• Chronic illness with leukemia, rheumatic and CHD, chronic kidney disease, etc

Pulpectomy – procedure
1. Use local anesthesia and isolate with rubber dam
2. Prepare a cavity preparation as dictated by carious lesion
3. Use a large round bur to remove remaining carious lesions and the debris in the pulp chamber.
4. After opening the pulp chamber, evaluate hemorrhage or purulent exudate
5. With endodontic file, remove diseased pulpal tissue from the root canals
6. Irrigate canals. Dry with cotton pellet and paper points
7. Fill canals with suitable filling material (ZOE, Iodoform paste, etc). Fill chamber with ZOE.
8. Obtain post-operative radiograph to verify obturation
9. Restore with SSC
10. Periodic recall

pulpectomy
Criteria for ideal root filling
• Antiseptic
• Resorbable
• Harmless to adjacent tooth germ
• Radiopaque
• Easily inserted
• Easily removed
• Biocompatible
Examples:
• Zinc oxide eugenol
• Calcium hydroxide
• Calcium hydroxide with Iodoform (Vitapex)