Clinical protocols in the

treatment of caries and its

complications in children and
adolescents

Prof. dr. Gateva

 Background
• The primary goal of pulp therapy is to maintain the integrity and health
of the teeth and their supporting tissues while maintaining the vitality of
the pulp of a tooth affected by caries, traumatic injury, or other causes.
• Especially in young permanent teeth with immature roots, the pulp is
integral to continue apexogenesis.
• Long term retention of a permanent tooth requires a root with a
favorable crown/root ratio and dentinal walls that are thick enough to
withstand normal function.
• The maintenance of vital pulp should be one of the main goals in the
treatment of young permanent teeth.
 Methods

Conservative treatment Radical treatment

Biological Endodontic

Indirect pulp Direct pulp Vital Revascularizat

Pulpectomy
capping capping pulpotomy ion

Vital pulp therapy

Indirect pulp capping
 Principles of carious dentin removal (excavation)

• Removal of carious dentin is a key part of the protocol in the

treatment of caries of primary and permanent children's teeth.
The following is a brief description of the main methods of
preparation/excavation, visual-tactile control of the cavity
preparation, according to the goals of treatment and the
respective diagnosis.
• Two main methods for removing carious dentin are discussed
in the present:
Nonselective removal of carious dentin.
• This is a method for complete excavation to hard (“free from
bacteria”) dentin. The aim is to remove soft caries tissue to reach
hard dentin resembling healthy dentin in all parts of the cavity,
including pulpally.
• Today, this method is not recommended as a main goal in the
treatment of deep dentinal caries in children. Excessive removal of
tooth structures is just as risky to contaminate the pulp, as it is to
preserve cariously damaged tissues. It may cause indirect damage to
the pulp from microbial irritants passing through the open dentinal
canals of the thin layer of suprapulp dentin.
Selective removal of carious
dentin.
It is recommended for both dentitions, for lesions reaching radiologically to the
innermost third or quarter of the suprapulp dentin. The method is of two types:
➢ Selective removal to firm dentin
➢ Selective removal to soft dentin - partially infected dentin
Selective removal to firm dentin – affected dentin.

Criteria of firm dentin:

• color - darker than the hard dentin;
• physically resistant to hand excavation;
• some pressure needs to be exerted through an instrument to lift
it (according to Bjorndal's visual-tactile criteria) and it leaves
white line in the dentin;
• fluorescent excavation control - pale pink fluorescence.
 Selective removal to soft dentin - partially
infected dentin.
• This technique is known as partial-caries removal, 1 step, ultraconservative,
or incomplete caries removal.
• It is used for deep and extensive carious lesions (entering the innermost
quarter of the suprapulp dentin), with no acute pulpitis symptoms, but the
presence of objective clinical criteria for asymptomatic closed pulpitis
(ACP).
• In this case, selective removal to firm dentin (affected) is risky for exposure
and contamination of the dental pulp. This method aims to stimulate
tertiary dentinogenesis, internal remineralization, and reduce residual
bacterial flora. The method is applicable in one or two visits, which is why it
is called a step method and corresponds to the biological method for the
treatment of asymptomatic closed pulpitis, called "indirect pulp capping".
 Criteria for soft dentin (partially infected):

• color – darker than the color of the firm dentin;

• under light pressure with a sharp excavator, the dentin is slightly
deformed and particles can be separated from it;
• when probing with light pressure, a slight sinking of the probe is
felt, which corresponds to "medium hard dentin" (according to
the visual-tactile scale of Bjorndal);
• in fluorescence control of excavation is observed - pale pink
fluorescence, with limited fields of red fluorescence in the
suprapulp area of dentin.
NB!

• In the selective removal of carious dentin, different excavation

criteria are used when assessing the periphery of the cavity to
the area in close proximity to the pulp.
• The periphery of the cavity should be surrounded by “sound”
enamel to allow the best adhesive seal. The peripheral dentin
should be hard – with similar tactile characteristics to sound
dentin
• In the area of the suprapulp dentin, selective removal of
carious dentin is to soft or firm dentin.
Visual-tactile scale of Bjorndal, for assessment of carious
dentin:
Visual criteria – Tactile criteria (with a probe) - dentin consistency
color of the dentin
Black very soft - the probe enters and easily peels off particles from it;
Dark brown soft dentin - the probe sinks without resistance and comes out of
the dentin;
Light brown leathery - slight resistance when probing
Yellow firm dentin - some pressure needs to be exerted through an
instrument to lift it and it leaves white line in the dentin when
probing
Light yellow hard dentin – resistant when probing, a scratchy sound or “cri
dentinaire” can be heard when a straight probe is taken across
the dentin .
 Criteria for fluorescence control of excavation by ProFace (Mitova):

• Infected dentin - the fluorescence has an intense red or dark red color,
which covers the entire carious dentin;
• Partially infected dentin - selectively removed to soft dentin - pink
fluorescence with localized limited red fields in the area of suprapulp
dentin;
• Affected dentin – selectively removed to firm dentin – pale pink
fluorescence, localized only in small fields from the bottom of the cavity (in
the area of the suprapulp dentin), and in the rest of the cavity lack of
fluorescence;
• Healthy dentin - non-selectively completely removed carious dentin - lack
of red fluorescence.
Protocols for Diagnostics
and Treatment of Deep
Dentinal Caries Lesion:
D3b (Peneva)/ code 05 ( ICDAS II)
D4 (Peneva)/ code 06 ( ICDAS II) – closed asymptomatic pulpitis
D3b (Peneva) code 05 - ( ICDAS II)
dentin caries affecting the dentin in the 0-no sealant or filling
inner half of the dentin without affecting 5-cavitation with visible carious dentin
the pulp
D4 (Peneva) code 06 ( ICDAS II)
dentin caries affecting the dentin in the 0-no sealant or filling
inner half of the dentin, affecting the pulp 6- Extensive cavitation (diffuse, wide) with
visible carious dentin

Description of the lesion stage

 • The aim is maximal preservation of the
hard tooth structures, which can
regenerate through selective removal of
the carious dentin, stimulation of the
tertiary dentinogenesis, internal
Goal of the remineralization and reduction of the
residual bacterial flora.
treatment:
• In the treatment of closed asymptomatic
pulpitis is added effect on the reversible
inflammation in the underlying pulp horn,
preservation of the vitality and the
integrity of the pulp.
Methods of treatment:
1. Minimally invasive treatment of deep dentin caries with selective
removal of carious dentin - in deep dentin caries D3b (Peneva) / code
05 (ICDAS II);
2. Biological treatment with selective removal of carious dentin and
indirect pulp capping - in closed asymptomatic pulpitis /carious lesion
D4 (Peneva) / code 06 (ICDAS II).
Indications:
• Both methods are applied to primary and permanent
children's teeth that respond the diagnostic criteria,
described below, corresponding to the diagnoses:
• Deep dentin caries D3b (Peneva)/ code 05 ( ICDAS II);
• Closed asymptomatic pulpitis/carious lesion D4
(Peneva)/ code 06 (ICDAS II) .
Contraindications:
Methods are not recommended:
• In all other carious lesions in the enamel and dentin;
• In all other cases of pulpitis: opened asymptomatic pulpitis, closed
asymptomatic pulpitis with acute pain symptom; opened
symptomatic pulpitis;
• In all cases of periodontitis;
• In children in whom controlled follow-up cannot be performed;
• In primary teeth in the period of physiological exfoliation;
• In teeth with severely destructed crowns that cannot be restored.
Diagnosis:
• Anamnestic data – lack of spontaneous pain
• Visual-tactile diagnostic criteria to be monitored:
• localization of the carious lesion;
• size and depth of the carious lesion;
• сolor and consistence of the carious dentin;
• lack or presence of pulp exposure.
• X-ray control: (intraoral Ro gr of the tooth) before the
treatment and on the 3rd month.
 Dentin caries D3b (Peneva)/ code 05 ( ICDAS II);
• size of the carious lesion responding the following clinical criteria, according to
location:
• occlusal lesion – cavitated dentin lesion, including less than ½ of adjacent cusp(s); lesions in
more than one fissure/ fossa are possible
• approximal lesion – cavitated dentin lesion which:
• in vestibulo-oral direction does not reach the self-cleaning surface;
• in medio-distal direction - does not reach half of the adjacent cusp;
• cervical lesion - has direct visibility; limited lesion in the dentin with medium depth;
• periphery of the lesion – fractured and undermined;
• enamel edges with transparent dark coloration of underlying carious dentin;
• сolor and consistency of the carious dentin – indicators for the rate of the carious
process;
• no pulp exposure;
• X-ray control (intraoral Ro gr of the tooth) – the lesion reaches the inner 1/3 of
the dentin, without data for pulp exposure.
Closed asymptomatic pulpitis /carious lesion D4 (Peneva) code 06 (ICDAS II)
– Extensive cavitation (diffuse) with visible carious dentin;

• size of the carious lesion - deep and extensive carious lesions responding the
following clinical criteria:
• occlusal lesion – deep and extensive dentin lesions, involving the last 1/4
of the suprapulp dentin, involving more than ½ of the adjacent cusp (s);
• approximal lesion – cavitated dentin lesion:
• in vestibulo-oral direction - reaching a self-cleaning surface;
• in medio-distal direction - reaching and exceeding the middle of an
adjacent cusp;
• in depth, reaching the last ¼ of the dentin.
• cervical lesion - has direct visibility; deep and extensive carious lesion in
the dentin.
Closed asymptomatic pulpitis /carious lesion D4 (Peneva) code 06 (ICDAS II)
– Extensive cavitation (diffuse) with visible carious dentin;

• Periphery of the carious lesion – cavitated from the occlusal, with fractured
and undermined enamel edges with transparent underlying carious dentin;
• color and consistency of the carious dentin – they determinate the rate of
the carious process;
• without pulp exposure;
• X-ray control (intraoral Ro gr of the tooth) – the carious lesion reaches the
innermost ¼ of the dentin.
 Differential diagnosis between:
• Dentin caries D3a – in the outer half of the dentin и D3b in the
inner ½ of the dentin (Peneva) – according to the described criteria
determining the size of the lesion;
• Deep dentin caries and closed asymptomatic pulpitis – according
to the described crteria;
• Reversible and irreversible pulpitis - absence or presence of
spontaneous night pain;
• Closed and opened pulpitis – absence or presence of pulp
exposure.
Treatment protocol for carious lesion
D3b (Peneva)/ code 05 ( ICDAS II)

The treatment is minimally invasive, in one visit, it is applied

for primary and permanent teeth
 Clinical protocol
1. Applying local anesthesia if necessary;
2. Isolation of the tooth, with rubber dam if possible;
3. Gain access to the carious lesion - is performed with a
diamond fissure turbine burr, aiming to remove the
undermined enamel edges and occlusal opening of the
carious lesion - creating access to the cavity;
4. Removal of the softest layer of carious dentin from the cavity
and reaching hard dentin in the area of DEJ. It is made with a
round steel burr, corresponding to the size of the cavity and
with slow rate;
 Clinical protocol
5. Removal of carious dentin to hard dentin from the cavity wall, 1-2 mm
from DEJ and carious dentin at the same depth from the middle of the
lesion. It is made with a round steel burr, corresponding to the size of the
cavity at slow rate.
• Criteria for assessment of the DEJ and 1-2 below it – “sound” dentin
• Color - light yellow, visible sound enamel, DEJ and sound dentin;
• Resistance when trying to remove it with hand excavator;
• Slight scratching sound and resistance when probing (according to the visual-tactile
scheme of Bjorndal);
• with fluorescence control of excavation - lack of red and pink fluorescence.
 Clinical protocol
6. Selective removal of the carious dentin to relatively firm dentin –
affected dentin.
• Criteria for affected dentin:
• Color – darker than the hard dentin;
• Resistance when trying to remove it with hand excavator;
• when moving with a sharp probe, a slight resistance is felt and a white line
remains (according to the visual-tactile scheme of Bjorndal);
• in fluorescence control of excavation - pale pink fluorescence.
7. Placement of a light-curing calcium hydroxide material (liner) and/or
base (only for permanent teeth) of GIC, which aims to stimulate tertiary
dentinogenesis, internal remineralization and has antimicrobial activity.
Clinical protocol
8. Final filling from composite material at the
same visit.
9. Control visits – during routine preventive
visitations.
• Possible complications – minimal risk of
compications.
Treatment protocol for closed
asymptomatic pulpitis/carious lesion
D4 (Peneva)/code 06 (ICDAS II)

The treatment is biological by indirect pulp cappin and

selective removal of carious dentin. It is used for primary and
permanent children's teeth.
 Clinical protocol
First visit:
1.Applying local anesthesia if necessary;
2.Isolation of the tooth, with rubber dam if possible;
3.Gain access to the carious lesion - is performed with a diamond
fissure turbine burr, aiming to remove the undermined enamel edges
and occlusal opening of the carious lesion - creating access to the
cavity;
4. Removal of the softest layer of carious dentin from the cavity and
reaching hard dentin in the area of DEJ. It is made with a round steel
burr, corresponding to the size of the cavity and with slow rate;
Clinical protocol
5. Removal of carious dentin to hard dentin from the cavity wall, 1-2
mm from DEJ and carious dentin at the same depth from the middle of
the lesion. It is made with a round steel burr, corresponding to the size
of the cavity at slow rate.
• Criteria for assessment of the DEJ and 1-2 below it:
• color - light yellow, demarcating from “sound” enamel, DEJ and “sound”
dentin;
• resistant to hand excavation
• Slight scratching sound and resistance when probing (according to the visual-
tactile scale of Bjorndal);
• in fluorescence control of excavation - lack of red and pink fluorescence.
6. Selective removal to soft dentin (partially infected dentin) with round
burr, with the following characteristics:
Criteria for soft dentin:
• Color – darker than the firm dentin;
• under light pressure with a sharp excavator, the dentin is slightly deformed and
dentin particles can be peeled;
• when probing with light pressure, a slight sinking of the probe is felt, which
corresponds to firm (according to the visual-tactile scheme of Bjorndal);
• in fluorescent control of excavation - pale pink fluorescence is observed, with
limited fields of redder fluorescence in the suprapulpual area of dentin.
• There is no pulp exposure.
• Look at the additional information
Clinical protocol
7. Application of a calcium hydroxide material (liner) and / or GIC for a base
(only for permanent teeth), which aims to stimulate tertiary dentinogenesis,
internal remineralization, and antimicrobial activity on residual bacterial
flora.
8. Temporary filling for 3 months. The material should ensure hermeticism of
the restoration.
• For permanent teeth - GIC (colorful GIC is recommended for easier control when
removing it);
• For primary teeth - IRM (polymer with ZnO – eugenol cement).
9. For primary teeth, a single-visit method is possible, with strict following of
described criteria and control, and the necessary clinical experience. The
treatment ends with the application of a calcium hydroxide material (liner)
and filling with compomer.
Second visit:
10. X-ray control – assessment of the the thickness of the suprapulp dentin;
11. The cavity is being revised. With a suitable round burr, the most superficial thin
layer of the preserved "soft dentin" is removed - it is not remineralized enough and
has a softer consistency and moisture than the underlying dentin; following the
protocol, there is no microbial activity;
12. Reaching a layer with the characteristics of affected dentin;
• In fluorescence control - absence of fluorescence;
13. Calcium hydroxide material (liner) and/or GJC (base for permanent teeth) is
placed again and final filling according to the indications;
14. Control visits: every six months, during a routine preventive visit.
• Possible complications:
• Exacerbation of pulp inflammation;
• Pulp necrosis;
• Calcifications in the pulp.
Direct pulp capping
Definition

• A procedure in which a pinpoint pulp exposure - up to 1

mm due to caries, collisio pulpae (iatrogenic injury such as
accidental exposure during cavity preparation or caries
removal) or trauma but surrounded by sound dentin is
coated directly with a suitable material (calcium hydroxide,
MTA, biodentin).
 to preserve the pulp health,
function and vitality;
to facilitate the formation of
tertiary (reparative) dentin;
Aim to stimulate the healing process;

to ensure the root development

of an immature permanent tooth

Pulpitis traumatica
• Fracture of the crown with pulp
exposure – not more than 24
hours after the trauma.
• Colisio pulpae - pinpoint pulp
exposure (< 1mm) surrounded
by sound dentin.
Diagnosis:
Reversible pulpitis
• Lack of nocturnal or spontaneous pain
• Controlled pulp bleeding, bright color
of the blood
• Provoked pain should be less than 1
minute when applying a thermal test
• Acceptable - discomfort during eating/
Possible provoked pain by chewing
Contraindications:
• Spontaneous pain
• Nocturnal pain;
• Tooth mobility;
• Uncontrolled bleeding – with purulent or serous exudate;
• Large pulp exposure - > 1 mm after the caries removal;
• Pulp exposure is in the cervical area of the tooth;
• Radiographic evidence of pulp pathology – external/internal root
resorption;
• Presence of swelling or sinus tract
 Prerequisites

• Accurate diagnosis - a guarantee of success of treatment

• The choice of the method is made finally after complete caries
removal untill reaching sound dentin around th exposure (up to 1 mm
in size);
• The tooth is restorable (there are enough tooth structures to ensure the
longevity of the restoration and the maximum sealing of the tooth)
• The methodology is performed in ONE SESSION
• Diagnostic X-ray - gives information about the location of the finding,
stage of root development, serves as a follow up control
• Maximum good isolation of the operating field
• Useage of sterile instruments
 Treatment protocol
1. Local anesthesia
2. Cavity preparation
• Mandatory following the successive steps (especially in a clinical
situation with a deep carious lesion).
2.1. Gain the access/establish the outline form of the carious lesion
is performed with a turbine (high-speed handpiece) with fissure
diamond bur and water-air spray cooling.
2.2. The removal of carious tissues is done with a stainless round bur
(with the appropriate size) and a low-speed handpiece - at slow
speed and direction from the bottom of the cavity to its surface
 Treatment protocol….
2. Cavity preparation
2.3. Complete removal of cariously damaged and affected tooth structures
• Enamel and EDJ - are cleaned to sound enamel and dentin - with fissure diamond
turbine bur and water-air cooling.
• The walls of the cavity - the carious dentin is removed - until healthy and sound
dentin.
• Criteria for evaluation of EDJ and 1-2 mm. below it, with removed carious dentin to
healthy:
• color - light yellow, distinguishing healthy enamel, EDJ and sound dentin;
• creates resistance when trying to remove it with the excavator;
• hard non carious dentine - when probing slightly creaking and resistance
(according to the visual-tactile criteria of Bjorndal);
• in fluorescent control of excavation - lack of red and pink fluorescence.
 Treatment protocol….
2. Cavity preparation…..
2.4. Bottom of the cavity
▪ Last, the carious dentin is removed from the bottom of the cavity - again to sound
dentin (see the criteria above) and last in the area of the pulp projection (pulp
horn).
▪ When the pulpal exposure is due to trauma, the above steps related to the
removal of carious tissues are not performed. Then proceed to rinsing the cavity
and pulp exposure.

3. Rinsing the cavity and communication with saline or distilled water

 Treatment protocol….
3.1. In case of bleeding - to be controlled:
• To be short (up to 2-3 minutes)
• Blood - with a bright red color
• For hemostasis - light pressure can be applied to the exposure site with a sterile
cotton pellet
3.2. Applying the pulp capping agent - with very light pressure so as not to get
into the pulp chamber.
• Materials for direct pulp capping
• Light curing calcium hydroxide material, followed by a base of light-curing resin-modified GIC;
• MTA - prepared ex tempore, applied on the pulp exposure in a thin layer and with the appropriate
tool. Press lightly, with a very slightly moistened (in saline or distilled water) sterile cotton pellet,
then place a base of light-curing resin-modified GIC on the MTA;
 Treatment protocol….
4. Placing a final filling (composite), which must ensure maximum
sealing.
4.1. When the pulp is exposed due to trauma - the filling is
made lower than the occlusal level for a period of 1 month;
• The final aesthetic restoration of anterior teeth - 1 month
after the traumatic event.
 Treatment protocol….
5. Follow-up appointments:
5.1. During the first year – once in
3 months (in the absence of
symptoms):
• Tooth vitality, control X-rays;
5.2. During the second year and in
the next 5 years – once in 6
months:
• Tooth vitality, control
radiographs.
6. Possible complications
6.1. Exacerbation
• In case of incorrect diagnosis
• In case of incorrect implementation
of the clinical protocol
6.2. Pulp necrosis
• Early - up to 2 years
• Late - over 2 years
6.3. Calcifications
• In the coronal pulp
• In the root pulp
 Direct pulp capping
7. In case of 8. Expectations after direct pulp capping:
failure: • Occurrence of a healing process in the pulp.
• Recovery of the biological activity of the pulp.
• Pulpotomy • Stimulation of:
• fibroblasts to form fibrous membrane production under the pulp
exposure;
• odontoblast-like cells around the pulp exposure to form tertiary
dentin production;
• formation of sclerotic dentin;
• cell differentiation of undifferentiated cells;
• Calcification of the fibrous membrane
• Teeth having immature roots should continue normal root
development and apexogenesis.
PARTIAL VITAL PULPOTOMY
 Definition:
• The partial pulpotomy for
carious exposures is a procedure
in which the inflamed pulp
tissue beneath an exposure is
removed to a depth of one to
three millimeters or deeper to
reach healthy pulp tissue.
Followed by the application of
dressing material on the rest of
the pulp in order to stimulate
healing and preserve this vital
tissue.
Purpose:
• To maintain the vitality of the
remaining healthy pulp tissue
• To ensure the healing process of
the reversible pulp inflammation
• To ensure the root development
of an immature permanent
tooth
 Diagnosis:
• Reversible asymptomatic pulpitis and especially in immature
permanent teeth;
• Controlled bleeding, with a bright color within a few minutes
• The provoked pain should be less than 1 minute.
• No nocturnal and spontaneous pain
• Acceptable - discomfort during eating/chewing
• In pulp exposure more than 1 or 2 mm, after completely removed
carious dentin;
• Complicated crown fracture with minimal pulp exposure - in
traumatic opening of the pulp, when it is 4 mm or less.
 Contraindications:
• Spontaneous pain;
• Night pain;
• Tooth mobility;
• Uncontrolled bleeding, purulent or serous exudate;
• Large pulp exposure;
• When pulp exposure is localized in the cervical area of the tooth;
• Radiographic evidence of pulp pathology - external/internal root
resorption;
• Presence of edema or fistula;
• Not recommended for primarty teeth
 Prerequisites
• Accurate diagnosis - a guarantee of success of treatment;
• The tooth should be restorable (enough dental structures to
ensure the longevity of the restoration and the maximum
sealing of the tooth);
• The methodology is performed in ONE SESSION;
• Diagnostic X-ray - gives information about the location of the
finding, stage of root development, serves as a follow up
control;
• To be formed ½ from the length of the root;
• Maximum good isolation of the working area ;
• Use of sterile instruments.
 Clinical protocol
1.Local anesthesia
2.Cavity preparation
• Mandatory following the successive steps (especially in a
clinical situation with a deep carious lesion).
• Gain the access/establish the outline form of the carious
lesion is performed with a turbine fissure diamond bur and
water-air cooling.
• The removal of carious tissues is done with a stainless round
bur (with the appropriate size) and low-speed handpiece, at
slow speed, direction from the bottom of the cavity to its
surface
Clinical protocol
• Complete removal of cariously damaged and affected tooth
structures
• Within the limits of enamel and EDJ - is cleaned to sound
enamel and dentin - with fissure diamond turbine bur and
water-air cooling.
• Cavity walls – cleaned until reaching healthy sound dentin
• Finally, the carious dentin is removed from the bottom of
the cavity - again to sound dentin and last in the area of
the pulp projection (pulp horn) - with a stainless round
bur and slow-speed handpiece, at slow speed.
 Clinical protocol
• Criteria for assessment of sound dentin during the cavity preparation:
• color - light yellow, distinguishing healthy enamel, EDJ and healthy dentin;
• creates resistance when trying to remove it with the excavator;
• slight creaking and resistance when probing (according to the visual-tactile criteria
of Bjorndal);
• in fluorescent control of excavation - lack of red and pink fluorescence.
• When the procedure is applied in case of trauma/fracture, the above steps
are not necessary.
• Pulp exposure is slightly expanded - carefully, with a thin sterile fissure diamond
turbine bur and water-air cooling;
• The pulp tissue is removed to a depth of 1 to 3 mm with another sterile fissure
diamond bur and water-air cooling, entering the pulp chamber from the site of
communication.
 Clinical protocol
• Bleeding - controlled:
• To be short (up to 2-3 minutes)
• To be with a clear red color
• Rinsing with bactericidal agent - sodium hypochlorite - 1% or chlorhexidine, placed in a sterile
syringe and needle
• Sterile cotton pellets for hemostasis moistened in saline are used.
• Applying the pulp dressing material - with light pressure.
• Materials for partial vital pulpotomy:
• Calcium hydroxide, followed by a base of light-curing resin-modified GIC;
• MTA - prepared ex tempore, applied on the communication and on the surrounding dentin in
a layer with a thickness of at least 1.5 mm, then above the layer of MTA is placed a base of
light-curing resin-modified GIC;
• Biodentin - similar to MTA. It is a more suitable pulp coating agent when performing the
procedure on frontal teeth, as it does not cause staining of the tooth structures unlike MTA.
• Definitive restoration - composite, which must provide maximum sealing.
 3.Follow-up appointments:
• During the first year – once in 3
months (in the absence of
symptoms):
• Tooth vitality, control X-rays;
• During the second year and in
the next years – once in 6
months:
• Tooth vitality, control radiographs
4.Possible complications
• Exacerbation
• In case of incorrect diagnosis
• In case of incorrect
implementation of the clinical
protocol
• Pulp necrosis
• Early - up to 2 years
• Late - over 2 years
• Calcifications
• In the coronal pulp
• In the root pulp
 6.Expectations after partial
5.In case of failure: vital pulpotomy:

• Pulpotomy • The residual root pulp must remain

vital;
• No symptoms such as sensitivity,
pain or swelling.
• There should be no radiographic sign
of internal or external resorption,
abnormal canal calcification, or
periapical radiolucency
postoperatively.
• Teeth having immature roots should
continue normal root development
and apexogenesis.
Vital pulpotomy
Definition
• Complete removal of the coronary part of the pulp,
keeping intact vital pulp tissues in the root canals,
followed by the application of dressing material on
the rest of the pulp in order to stimulate healing and
preserve this vital tissue.
Definition
• Complete removal of the
coronary part of the pulp,
keeping intact vital pulp tissues
in the root canals, followed by
the application of dressing
material on the rest of the pulp
in order to stimulate healing and
preserve this vital tissue.
Purpose
• Removal of the inflamed and
infected pulp at the site of the
pulp exposure will create an
opportunity to preserve the
vitality of the root pulp and its
healing. This will ensure normal
root development, especially in
immature permanent teeth.
Diagnosis - especially appropriate technique for
immature permanent teeth.
• Reversible symptomatic closed • Pulp exposure after a trauma
pulpitis - when the inflammation • If it is more than 1 mm wide
is limited to the coronal pulp • If it is located in the cervical area
and when there are
contraindications for the
application of indirect or direct
capping.
• Short-term spontaneous pain -
incidental, short-term, with long
remissions.
• Provoked pain - about 1 minute (in
case of thermal irritation)
Controlled bleeding from the pulp exposure - up to 2-3 minutes
with a bright red color of the blood
 Contraindications:
• Spontaneous pain;
• Nocturnal pain with frequent prolonged attacks;
• Tooth with pathological mobility;
• Percussion sensitivity;
• Uncontrolled bleeding, purulent or serous exudate;
• Large size of the pulp exposure - more than 1-2 mm.;
• When the pulp exposure is localized in the cervical area of the teeth (except in case of
traumatic pulpitis);
• Radiographic evidence of pulp pathology – external/internal root resorption;
• Periapical or interradicular radiolucency ;
• Pulp calcification;
• Presence of edema orsinus tract;
• Large, extensive crown destruction - without the possibility of hermetic seal;
• General medical contraindications - heart disease, immunocompromised patients.
 Prerequisites
• Accurate diagnosis - a guarantee of success of treatment;
• The tooth should be restorable (enough dental structures to ensure the
longevity of the filling/restoration and the hermetic seal of the tooth);
• The methodology is performed in ONE SESSION;
• Diagnostic X-ray - gives information about the location of the findings,
stage of root development, serves as a follow up control;
• To be formed at least ½ from the length of the root;
• Maximum good isolation of the operation field;
• Use of sterile instruments.
 Treatment protocol
• Local anesthesia;
• Rubber dam placement;
• Cavity preparation
• Mandatory following the successive steps (especially in a clinical
situation with a deep carious lesion).
• Gain the access/establish the outline form of the carious lesion is
performed with a turbine fissure diamond bur and water-air cooling;
• The removal of carious tissues is done with a stainless round bur
(with the appropriate size) and a low speed handpiece, at slow
speed, with direction from the bottom of the cavity to its surface.
 Treatment protocol
• Complete removal of cariously damaged and affected tooth structures
• Within the limits of enamel and EDJ - is cleaned to sound enamel and
dentin - with fissure diamond turbine bur and water-air cooling.
• Cavity walls - carious dentin is removed - to sound dentin
• Criteria for evaluation of EDJ and 1-2 mm. below it, with removed
carious dentin to healthy:
• color - light yellow, distinguishing healthy enamel, EDJ and healthy
dentin;
• creates resistance when trying to remove it with the excavator;
• hard non carious dentine - when probing slightly creaking and
resistance (according to the visual-tactile criteria of Bjorndal);
• in fluorescence control of excavation - lack of red and pink
fluorescence.
 Treatment protocol
• A cavity is prepared to provide endodontic access for the coronal pulp
amputation.
• Finally, the carious dentin is removed from the bottom of the cavity -
again to sound dentin and last in the area of the projection of the pulp
tissue.
• When the pulp exposure is due to trauma, the above steps related to the
removal of carious tissues are not performed. Then proceed to rinsing the
cavity and theexposure site.
• The tectum pulpae is removed - it starts from the place of the exposure.
This step is performed with a thin sterile fissure diamond turbine bur and
water-air cooling.
• With a thin fissure sterile diamond or carbide turbine bur, with an
inactive tip and water air cooling, enter the pulp chamber and amputate
(remove) the coronal pulp.
 Treatment protocol
• Bleeding – to be controlled:
• To be short (up to 2-3 minutes)
• To be with a bright red color
• rinsing with bactericidal agent - sodium hypochlorite - 1% or
chlorhexidine, placed in a sterile syringe and needle
• Sterile cotton pellets for hemostasis moistened in saline are
used.
• After the bleeding has stopped, the pulp wound should have a
homogeneous red appearance.
• Applying the pulp capping material - with light pressure.
 Treatment protocol
• Materials for direct pulp capping:
• Calcium hydroxide (nonsetting), followed by a base of light-
curing resin-modified GIC;
• MTA - prepared ex tempore, applied to the pulp wound. A light-
curing resin-modified GIC is then placed on the MTA layer;
• Biodentin - similar to MTA. It is a more suitable pulp capping
agent when performing the procedure on anterior teeth, as it
does not cause discoloration of the tooth structures unlike MTA.
• Final restoration – resin composite, which must provide maximum
sealing.
Follow-up appointments:

• During the first year – once in 3 months (in the

absence of symptoms):
• Tooth vitality, control radiographs;
• During the second year and in the next years –
once in 6 months:
• Tooth vitality, control radiographs
Possible complications In case of failure:
• Exacerbation • Pulpectomy
• In case of incorrect diagnosis
• In case of incorrect
implementation of the clinical
protocol
• Pulp necrosis
• Early - up to 2 years
• Late - over 2 years
• Calcifications
• In the coronal pulp
• In the root pulp
 Expectations after pulpotomy:
• The residual radicular pulp must remain vital
• Causes a protective-inflammatory reaction;
• Formation of fibrous tissue, which calcifies - calcium metaplasia of the
fibrous wound surface
• No symptoms such as sensitivity, pain or swelling.
• There should be no radiographic sign of internal or external
resorption, abnormal canal calcification, or periapical radiolucency
postoperatively.
• Teeth having immature roots should continue normal root
development and apexogenesis.
Endodontic Method for Treatment of
Pulpitis in Immature Permanent Teeth
It is applied in cases of closed and opened symptomatic pulpitis, failure of previous
treatment with biological or partially biological methods, fracture of the crown into
the cervical area. The method of endodontic treatment of immature permanent
teeth is partial pulpectomy.
PARTIAL PULPECTOMY
Definition:
• Complete removal of the
coronal pulp and part of the
radicular.
Aim:
• Removal of the irreversibly
inflamed coronary and radicular
pulp and preservation of a part
of the radicular pulp to ensure
the continuation of the root
development (technique for
apexogenesis). Apexogenesis is a
histological term that describes
the continuation of physiological
root development and formation
of the root apex.
Indications:
• Closed or opened
symptomatic pulpitis;
• Unsuccessful biological or
partially biological methods
of treatment, appearance of
spontaneous or night pain;
• Fracture of a permanent
tooth to the level of the
cervical area
Application criteria:
• Spontaneous and night pain,
typical for pulpitis;
• Immature permanent teeth;
• Developed at least ½ of the root
length;
• No percussion or palpation pain;
• Lack of redness of the mucosa in
the area around the roots and
periapical pathology
Requirements before the beginning of the treatment:
• Correct diagnosis – guarantee for success of the treatment;
• Teeth that are restorable (to have enough tooth structures that can
ensure the maximum sealing and resistance of the filling);
• The methodology is multi-session;
• Diagnostic X-ray – gives information for the localization of the lesion,
stage of the root development, it is used for control;
• Maximum isolation of the field;
• Use of sterile instruments;
• Developed at least ½ of the root;
 Clinical protocol - First visit:
• Local anesthesia, isolation with rubber dam and opening an access
cavity to the entire surface of the pulp tectum by completely
removing the infected dentin from the walls of the cavity and then
from the bottom;
• After reaching a communication with the pulp chamber the roof of
the pulp is removed with a sterile fissure or carbide turbine burr
with an inactive tip, until full access to the coronary pulp is
achieved;
• Removal of the coronal pulp with a sterile steel round burr;
• Irrigation with saline solution, drying with sterile cotton pellet;
 Clinical protocol - First visit:
• With a canal instrument (H-file) corresponding to the width of the
root canal, a stepwise removal of the root pulp is performed. It is
made in small portions and irrigation with saline is done until
bright blood appears and bleeding is controlled within a
physiological period of 2-5 minutes;
• Follows irrigation alternating 2,5% sodium hypochlorite and 17%
EDTA;
• Application of disinfecting medication – a sterile cotton pellet with
Indextol or Ledermix below the level of the orifice.
 Clinical protocol - Second visit (after 2 days):

• Anamnesis for any complaints from the previous 2 days;

• Anesthesia, isolation and irrigation – same as the previous
visit;
• Keeping complete sterility in the cavity is a must!
• Drying the root canal with paper points;
 Clinical protocol - Second visit (after 2 days):
• Filling of the root canal with material that will ensure the apexogenesis:
• Calcium hydroxide – regular follow-up visits, monitoring the amount of
calcium hydroxide by radiography. After resorption of the calcium hydroxide,
it is necessary to reopen the tooth and refill the root canal in a sterile
environment with special attention to the wound surface, not to disrupt the
healing process.
• After achieving apexogenesis, confirmed radiographicaly, proceed to routine
endodontic treatment;
• МТА – the material is applied with a plugger to the level of the pulp wound.
with light pressure and with a thickness of 2-3 mm. It is condensed passively
with an ultrasonic tip, touched to the plugger. It should be pressed lightly with
a saline-moistened cotton pallet. The tooth is closed with a temporary filling.
The next day, the hardness of the cement is checked and the tooth is
restored.
Follow-up
• Every three months during the
first year – checking the vitality,
X-ray.
• During the second year and the
next 5 years – every 6 months –
vitality of the tooth, control X-
ray.
Possible complications:
• Exacerbation of the
inflammation – in cases of
incorrect diagnosis, or mistakes
during the application of the
protocol;
• Pulp necrosis - early (in the first
2 years), late (after 2 years)
• Calcifications – root pulp.
• In case of failure – treatment
corresponding to the
complication.
Endodontic Treatment of Immature
Permanent Teeth and Necrotic Pulp
(in cases of apical periodontitis)
Definition: Aim:
• Endodontic therapy of • Induction of the closue of the
immature permanent apex in an immature tootht by
teeth and pulp necrosis removal of coronary and
due to caries or radicular non-vital pulp tissue
traumatic injury. and placement of a
biocompatible material, such as
calcium hydroxide for
disinfection of the endodontic
space. To create an apical hard
tissue barrier to allow filling of
the root canal.
• Indications: all cases of chronic apical
periodontitis, and exacerbations of chronic
periodontitis in immature teeth after the
chronicity of the process.

• Contraindications: In immunocompromised
patients, organ transplant patients.
 Diagnoses:
• Symptomatic apical periodontitis (Periodontitis symptomatica apicalis) –
occurrence of specific periodontal (in childhood – periapical) pain: constant
severe pain which is the reason for the visit in the dental office, pain during
percussion, pressure and chewing. The mucosa which covers the periapical
region is painful. The tooth feels higher than the other teeth and the contact
with the antagonist is painful.
• Acute apical abscess (Abscessus apicalis acuta) – quick appearance,
spontaneous pain, pain under pressure, rapid development, spontaneous
pain, pressure pain, pus formation and swelling of the tissue around the
affected tooth. Depending on the jaw in which the tooth is located, the
swelling may involve the sublingual area or a palatal abscess may form. The
swelling may affect the cheeks and orbit.
 Diagnoses:
• Asymptomatic periapical disease (Periodontitis asymptomatica apicalis) the
symptom "periodontal pain" is not present, without prolonged pain, there is no
pain or slight pain on percussion, palpation and pressure. There is no erythema of
the mucosa in the periapical area. Such apical periodontitis may not be noticed by
the patient and can be found accidentally during examination or on routine x-ray.
The data that the tooth is non-vital, as well as the stage of root development of the
contralateral tooth are important.
• Chronic apical abscess (Abscessus apicalis chronica) - prolonged beginning, mild to
absent discomfort with gradual release of the pressure through a formed sinus
tract. It may be the result of a naturally occurring exit of purulent exudate in an
acute process that leads to chronicity. The fistula is a typical feature of chronic
periapical abscess. It passes through the periapical structure, the bone, perforates
the periosteum and corticalis, and then the soft tissues around the root of the
tooth. It provides continuous drainage of the accumulating exudate in the oral
cavity. In very rare cases, the sinus tract can come out extraorally through the skin.
 Necessary requirements:
• Correct diagnosis – guarantee for the treatment success;
• The tooth should be restorable (enough tooth structures to
ensure the stability and the hermeticism of the filling)
• Diagnostic X-ray– gives information for the localisation of the
lesion, the stage of the root development, it is used later for
control;
• Maximum good isolation of the field;
• Use of sterile instruments.
Treatment protocol:
 Apexification with calcium hydroxide:
• The procedure requires multiple visits and assistance from the patients
and their parents, as it may take a year or more to achieve the formation
of an apical barrier to allow the root canal obturation.
• Calcium hydroxide helps disinfection of the root canal, as it increases the
dissolution of necrotic tissue when used alone or in combination with
NaOCl. The high pH and solubility of calcium hydroxide preserves its
antimicrobial effect in the root canal for a long time.
• The barrier is formed by cells originating from the adjacent connective
tissue. It is histologically porous and may consist of cementum, dentin,
bone or osteodentin.
Treatment protocol for asymptomatic apical
periodontitis and chronic apical abscess – first visit
• Local anesthesia and isolation with rubber dam;
• Opening an endodontic cavity to provide access to the entire surface of the
tectum pulpae for the respective tooth;
• Complete removal of the infected dentin first from the walls of the cavity and
then from the bottom;
• Rinsing and drying the cavity before opening the pulp;
• A thin sterile fissure burr enters the communication with the pulp and the tectum
of the pulp is removed along its contours until full access to the pulp cavity;
• Mechanical and chemical treatment of the root canal. Multistage and gradual
cleaning is performed with a K-file, under irrigation with antiseptic solutions -
2.5% sodium hypochlorite and EDTA;
• Determination of the working length radiographically. Apexlocators are not
reliable in cases of immature teeth;
Treatment protocol for asymptomatic apical
periodontitis and chronic apical abscess – first visit
• Disinfection of the root canal:
• careful irrigation with 2.5% sodium hypochlorite with a syringe and a needle with a
side opening, in order to dissolve the necrotic pulp tissues;
• The needle should not tighten in the root canal and the working length is shorter to
avoid extrusion of solution through the apical foramen;
• Passive ultrasonic activation of the solution is recommended to make the removal of
necrotic tissues easier.
• Irrigation with saline solution;
• Drying the canal with sterile paper points;
• Placing antiseptic dressing in the root canal in 1, 2 or more visits, in
combination with irrigation according to the clinical situation (exudation,
gangrenous odor from the canal).
Treatment protocol for asymptomatic apical
periodontitis and chronic apical abscess
SECOND VISIT
• Irrigation of the canal and application of non-hardening calcium
hydroxide (in length shorter than the working length) with a cannula, and
pressing with a sterile cotton pellet;
• Temporary filling which ensures hermeticism for a longer period of time
(GIC, IRM).
NEXT VISIT: 2-3 WEEKS LATER;
• Disinfection of the root canal;
• Application of new portion of calcium hydroxide paste in the root canal,
apically from the enamel-cement junction;
• Long-term sealing of endodontic access.
Control visits:
• The tooth is observed clinically and radiographically at 3-
month intervals: during these 3 months it may be necessary
to refill the tooth with calcium hydroxide, because the paste
is absorbed very quickly!
• the filling of calcium hydroxide paste;
• presence of an initial barrier;
• thickening or possible elongation of the root walls;
• condition of the periapical bone and periodontal space.
 NB!
• If the radiograph shows that calcium hydroxide has been resorbed from
the canal, the procedure is repeated. If the canal remains filled and
partial progress is seen in the formation of the apical septum, the tooth is
left for another three months.
• The procedure is repeated every three months until the final formation of
a hard apical septum, until thickening or elongation, formation of
periodontal space and formation of lamina dura of the alveolar bone.
• The barrier can be formed coronally from the apex of the root and in this
case the working length is reduced. This septum should not be perforated
to fill the canal to the apex, as the tissue that forms it is healthy.
• After the formation of the apical barrier, the canal is filled with gutta-
percha and a sealer.
Apexification with МТА:
Advantages:
• Shorter treatment time – apexification in one visit;
• Prevents microleakage;
• Possibility to harden in a humid environment;
• Reduced costs and clinical time.
 Clinical protocol:
• First visit – the same as for the apexification with calcium hydroxide.
• Second visit – after 2 weeks.
• Isolation with rubber dam, irrigation;
• Drying the root canal with paper points;
• Application of collagen matrix apically (optional);
• Placement and compaction (using ultrasound) of MTA in the apical part of
the root (4-5 mm) - the placement of MTA in the apical part is more
complicated than the use of calcium hydroxide. The material is placed with
the help of special endodontic pluggers and is compacted by indirect
ultrasonic activation. A moist cotton pellet or paper point is placed on the
MTA, providing moisture for it to harden, and the tooth is sealed with a
temporary filling.
 Third visit:
• After few days;
• The hardness of the cement is checked with an endodontic instrument;
• If the material is not hardened - a new one must be applicated;
• After hardening - filling of the root canal and restoration;
• The short setting time (~ 10 min) of some new generations of calcium
silicate cements may shorten the treatment period, allowing the
placement of an apical plug, root canal filling and restoration of the
tooth in one visit.
Treatment protocol for
symptomatic apical periodontitis:
 First visit:
• After diagnosis:
• If the tooth has a filling, it should be removed;
• If the tooth is not treated, an endodontic cavity is opened and the carious
tissue is removed;
• Removing the roof of the pulp cavity;
• Serous or purulent exudate, and sometimes bloody exudate comes out;
• Cleaning the necrotic tissue of the cavum;
• Irrigation with sodium hypochlorite;
• If possible, the tooth is sealed hermetically.
 The next visit
• Is on the following day. Again the same cleaning and disinfection
are done. These procedures are applied until the complete
disappearance of clinical symptoms.
• Sealing the tooth - after the protocol for disinfection of the root
canal, the tooth is left with an applicated drug in the root canal -
Ledermix, triple antibiotic paste or Indextol. It is sealed with
temporary filling;
 The next visit
• In case of successful sealing without complaints, one of the
apexification techniques is applied.
• After achieving the apexification, a routine root filling and
restoration of the tooth with permanent filling is done.
Treatment protocol for acute
apical abscess:
 Clinical protocol
• Drainage of the tooth - opening the pulp cavity, cleaning and creating a way to drain
the exudate from the root canal and periapical area. The tooth is left open;
• In the submucosal phase - incision for drainage of purulent exudate from the soft
tissues, leaving drainage;
• Influence of the general condition:
• a broad-spectrum antibiotic is required to affect the anaerobic microflora;
• Sultamicillin – suspension 250 mg/5ml - dose for children is per kilogram of body
weight for 24 hours - 100-150 mg in three doses;
• The best for periapical abscess is Amoxicillin/Clavulanic acid – 25-50-80 mg/ kg/24 h in three doses
+ Metronidazole - 20-30 mg/ kg/weight in 3 doses for 24 hours;
• Clindomycin - suitable for Gr(-), Gr(+) cocci and anaerobic microflora - 15–45 mg per kg/weight for
24 hours in 3-4 doses with 200 ml of water;
• Lincomycin - 30-60 mg/kg/weight for 24 hours in 3-4 doses.
• Cefador (cephalosporin II generation) - 20-30 mg per kg/weight for 24 hours in 3 doses before
meals; Antipyretics for normalizing the temperature;
• Inclusion of probiotics, vitamins and hydration with liquid intake;
 Clinical protocol
• Irrigation of the root canal and monitoring of the general condition is
done every day until the symptoms disappear. This usually happens after
the fifth or seventh day.
• Irrigation and disinfection of the root canal;
• Placing antibiotic paste in the root canal;
• Apexification technique according to the described protocol.

• In case of failure of the therapy: retreatment, extraction.