Primary Pulp

• Morphological Differences:

  • Increased number of accessory canals

  • Flat ribbon shaped canals

  • More open apices

  • Greater curvature of molar roots

  • Relatively longer more slender roots in molars

  • Larger pulp relative to crown size

  • Pulp horns closer to outer surface of tooth

  • Mesial pulp horns closer to surface than distal

  • Apical physiologic resorption

  • Presence of succedaneous tooth

Pulpal Diagnosis

1. Healthy (normal) pulp

2. Reversible pulpitis: Inflamed pulp capable of healing

3. Irreversible pulpitis: Inflamed pulp incapable of healing

4. Necrotic pulp

Clinical Diagnosis

• Comprehensive medical history

• Dental history with chief complaint

• Subjective evaluation of current symptoms

• Objective examination (extraoral and intraoral soft and hard tissue)

• Radiographic examination

• Clinical tests: palpation, percussion, mobility

• Pulp testing: EPT & thermal tests unreliable in primary and immature permanent teeth

• Direct pulpal observation as the final diagnostic step

Pain Evaluation Questions

• When did symptoms start

• Point specifically where in your mouth the pain is coming from

• Wong-Baker pain scale

• Describe pain: sharp, dull, aching, throbbing, etc.

• Is pain constant or does it come and go

• Does anything make the pain worse (hot/cold food, sweet/spicy food, biting, etc.)

• If there is anything that triggers pain, does the pain linger or go away quickly

• Does anything make the pain better (OTC pain medication)

• Does it hurt to eat

• Does it hurt when you are trying to sleep or watch tv

Healthy Pulp

• Clinical and Radiographic exam often reveals caries that are superficial to moderate in depth

• No history of pain associated with carious lesions

• Soft tissue and supporting periodontal structures normal

• Primary teeth with diagnosis of “healthy” pulp requiring pulp therapy should be treated with vital pulp therapy

Reversible Pulpitis

• Clinical and Radiographic exam often reveals caries that are moderate to deep and may be approximating the pulp

• Non-spontaneous pain

• Pain of short duration that does not linger

• Pain relieved with OTC analgesics, removal or stimulus, or brushing away plaque and food debris

• Absence of signs or symptoms of irreversible pulpitis

• Primary teeth with diagnosis of “reversible pulpitis” requiring pulp therapy should be treated with vital pulp therapy

Irreversible Pulpitis

• Clinical and Radiographic exam often reveals caries that are moderate to deep and may be approximating the pulp

• Spontaneous unprovoked pain

• Nocturnal pain (while sleeping or relaxing watching tv)

• Pain not relieved with OTC analgesics, removal or stimulus, or brushing away plaque and food debris

• Signs of irreversible pulpitis: sinus tract, excessive mobility, furcation/apical radiolucency, radiographic evidence of internal/external non-physiologic root resorption

• Primary teeth with diagnosis of “irreversible pulpitis” requiring pulp therapy should be treated with nonvital pulp therapy

Necrotic Pulp

• Clinical and Radiographic exam often reveals caries that are moderate to deep and may be approximating or into the pulp

• May or may not have current symptoms of pain

• Ask about periods of pain in the past

• Signs of necrotic pulp: sinus tract, excessive mobility, furcation/apical radiolucency, radiographic evidence of internal/external non-physiologic root resorption

• Primary teeth with diagnosis of “necrotic” pulp requiring pulp therapy should be treated with nonvital pulp therapy

Characterize Pain

Radiographic Interpretation

• Furcation or periapical changes

• Widening of the PDL

• Destruction of supporting bone (lamina dura & alveolar trabeculation)

• Pathologic root resorption

• Proximity of carious lesion to the pulp not always accurately determined from radiograph

• Inflammatory response of the pulp can not be accurately diagnosed on radiograph

Treatment Considerations

• Patient’s medical history

• Value of each tooth in relation to child’s development

• Restorability of the tooth

• Consider extraction when:

  • Infectious process cannot be arrested

  • Bony support cannot be regained

  • Inadequate tooth structure remains

  • Excessive pathologic root resorption exists

• Evaluation of treatment prognosis:

  • Pulp treatment/restoration vs. extraction/space maintenance:

    • importance of maintaining tooth in arch for continued development

    • more likely to elect to perform pulp therapy vs extraction on primary second molar to prevent mesial drift/tipping of permanent first molars

  • Other considerations:

    • patient and parent cooperation/motivation

    • Caries activity of patient and prognosis of rehabilitation

    • Stage of dental development

    • Degree of difficulty in performing procedure

    • Space management issues

• Isolation:

  • Necessary to minimize bacterial contamination and to protect soft and hard tissues

  • Rubber dam isolation is gold standard for pulpal treatment

  • If unable to use rubber dam, other isolation may be considered

• Anesthesia:

  • Profound anesthesia is a requirement for pulpal therapy

  • Beware of teeth with acutely inflamed pulp (hot teeth)

• Use of sterile burs and instruments required:

• Direct pulpal observation: The final diagnostic step

  • Size of exposure and degree of inflammation are directly related

  • Watery exudate or pus at site of pulpal exposure indicative of pulpal necrosis

  • Black or white pulp coloration indicative of pulpal necrosis

  • No bleeding of pulp tissue indicative of pulpal necrosis

  • Excessive bleeding of pulp that is not controlled by pressure of damp cotton pellet in 2-5 min indicative of irreversible pulpitis

  • Pink to red pulp tissue with bleeding controlled by pressure of damp cotton pellet in 2-3 min indicative of healthy or reversibly inflamed pulp

Vital Pulp Therapy in Primary Teeth

1. Protective liner

   • Tooth with a normal pulp and complete caries removal

   • A thinly-applied material placed on dentin in proximity to underlying pulpal surface of deep cavity prep

   • MTA, trisilicate cements, calcium hydroxide, or other biocompatible material

   • Protective barrier between the restorative material and pulp

   • To minimize injury to the pulp, promote pulp tissue healing and tertiary dentin formation, and/or minimize post- operative sensitivity

2. Indirect pulp treatment (IPT)

   • Deep caries lesion approximating the pulp

     • No pulpitis or reversible pulpitis

   • Leaves the deepest caries adjacent to the pulp undisturbed in an effort to avoid a pulp exposure

     • Margins must be caries free to establish an adequate seal during restoration

   • Caries-affected dentin is sealed with biocompatible material

     • Stimulate healing and repair

     • Examples: Resin modified glass ionomer (Vitrebond), calcium hydroxide (Dycal), or MTA (or any other biocompatible material)

   • Tooth restored with a material that seals the tooth from microleakage

3. Direct pulp cap

   • A pinpoint exposure (one millimeter or less) of the pulp is during cavity preparation (mechanical exposure) or following traumatic injury

   • Biocompatible radiopaque base such as MTA or calcium hydroxide placed in contact with the exposed pulp tissue

   • Tooth is restored with material that seals tooth from microleakage

   • Pulp healing and reparative dentin formation should result

   • Not typically performed for carious exposures on primary teeth

4. Pulpotomy

   • Caries removal results in a pulp exposure in a tooth with a normal pulp or reversible pulpitis or after a traumatic pulp exposure

   • Coronal pulp is amputated, pulpal hemorrhage controlled, and remaining vital radicular pulp tissue surface is treated

Pulpotomy Medicaments

• Only MTA and formocresol are recommended as the medicament of choice for teeth expected to be retained for 24 months or longer

• Ferric sulfate, lasers, sodium hypochlorite, and tricalcium silicate have also been used but have conditional recommendations based on a review of the literature according to the AAPD

• Calcium hydroxide is NOT recommended for pulpotomy

Pulpotomy Success

• Asymptomatic without sensitivity, pain or swelling

• No postoperative radiographic evidence of pathologic external root resorption

• Monitor internal root resorption

  • May be self-limiting and stable

• Remove tooth if clinical signs of infection or inflammation

• Success

  • Clinical > radiographic > histological

In vital primary teeth with deep carious lesions treated with pulpotomy due to pulp exposure during caries removal, does the choice of medicament or technique affect success?

• Systematic review

• Overall success rate at 24 months for MTA, formocresol, FS, NaOCl, calcium hydroxide, and laser → 82.6 percent

• MTA and formocresol success rates were the highest and not significantly different ○ MTA → 89.6% ○ Formocresol → 85.0%

• Recommends the use of MTA or formocresol ○ Strong recommendation, moderate-quality evidence

• Recommends AGAINST the use of calcium hydroxide

Pulpotomy Steps

1. Pulpal Diagnosis

2. Appropriate anesthesia, proper isolation, sterile burs & instruments

3. Caries removal → pulp exposure

4. Pulp access:

   1. Complete removal of roof of pulp chamber necessary

   2. Removal of all caries and overhanging dentin to allow clear access

5. Removal of coronal pulp tissue

   1. Pain during pulp removal may indicate hyperemia → non-vital pulp therapy or extraction

   2. Funnel shaped access to canals, with pulp amputated to this level

   3. No tissue tags remain

6. Achieve hemostasis with damp cotton pellets (use sterile water)

7. Remove all cotton pellets

8. Examine pulp →

   1. Bleeding after treatment may indicate hyperemia → non-vital pulp therapy or extraction

9. May gently disinfect chamber with cotton pellet soaked in sodium hypochlorite

10. Place MTA on pulp stumps with enough material to completely cover all exposed pulp

11. Fill chamber with base (GI, ZOE, Tempit)

12. Restore tooth (full coverage restoration preferred)

Non-vital Pulp Therapies in Primary Teeth

1. Pulpectomy

2. Lesion sterilization/tissue repair (LSTR)

Pulpectomy Indications

• Tooth with irreversible pulpitis or necrosis (due to caries or trauma)

• Tooth treatment planned for pulpotomy in which the radicular pulp exhibits clinical signs of irreversible pulpitis or pulp necrosis (e.g., suppuration, purulence)

• Roots should exhibit minimal or no resorption

Pulpectomy Steps

• Pulp access:

  • Complete removal of roof of pulp chamber necessary

  • Removal of all caries and overhanging dentin to allow clear access

• Complete pulpal debridement with hand or rotary files:

  • Pulp chamber AND root canals are debrided

  • Use radiographs for working length

  • Care not to force instruments through apex

• Irrigation & Disinfection of canals with sodium hypochlorite (care must be taken not to force irrigation fluid out of apicies)

• Canals dried with paper points

• Filled with resorbable material

  • Vitapex or Kri-paste

• Fill chamber with GI, ZOE, Tempit, etc.

• Restored with a restoration that seals the tooth from microleakage → full coverage restoration

• Evaluate non-vital pulp treatments for success and adverse events clinically and radiographically at least every 12 months.

Lesion Sterilization Tissue Repair (LSTR) Indications

• Primary tooth with irreversible pulpitis or necrosis

• When a tooth is to be maintained for less than twelve months and exhibits root resorption LSTR is preferred to pulpectomy

• Steps

  • Primary tooth with irreversible pulpitis or necrosis

  • After opening pulpal chamber, canal orifices are enlarged using a large round bur to create medication receptacles

  • No instrumentation of the root canals

  • Walls of the chamber are cleaned with phosphoric acid, rinsed and dried

  • A three antibiotic mixture of clindamycin, metronidazole, and ciprofloxacin is combined with a liquid vector to form a paste

  • Paste placed directly into the medication receptacles and over the pulpal floor → disinfect the root canals

  • Covered with glass-ionomer cement and full coverage restoration

  • When a tooth is to be maintained for less than twelve months and exhibits root resorption, LSTR is preferred to pulpectomy

Vital Pulp Therapy in Immature Permanent Teeth

• Protective liner

• Indirect pulp treatment

  • see slides under vital pulp therapy in primary teeth

• Direct pulp cap

• Partial pulpotomy for carious or traumatic exposure (Cvek pulpotomy)

• Complete pulpotomy

• Apexogenesis (root formation)

Direct Pulp Cap

• Permanent tooth with small carious, mechanical or traumatic exposure in a tooth with a normal pulp

• Hemorrhage control is obtained

• Exposed pulp is capped with a material such as calcium hydroxide or MTA

• Restoration that seals the tooth from microleakage

Partial pulpotomy for carious exposure

• Young permanent tooth with carious pulp exposure

• Vital tooth with diagnosis of normal pulp or reversible pulpitis

• Inflamed pulp tissue beneath an exposure is removed to a depth of 1-3mm or deeper to reach healthy pulp tissue

• Pulpal bleeding controlled (within several minutes) by irrigation with a bacteriocidal agent

  • Sodium hypochlorite or chlorhexidine

• Exposure covered with calcium hydroxide or MTA

• MTA (at least 1.5 millimeters thick) should cover the exposure and surrounding dentin followed by a layer of light cured resin-modified glass ionomer

• Restoration that seals the tooth from microleakage is placed

Partial Pulpotomy for traumatic exposure (Cvek pulpotomy)

• Vital, traumatically-exposed, young permanent tooth, especially one with an incompletely formed apex

• Inflamed pulp tissue beneath an exposure that is 4mm or less in size removed to a depth of 1-3mm or more to reach the deeper healthy tissue

• Pulpal bleeding controlled using irrigants (ex. sodium hypochlorite or chlorhexidine) and site is covered with calcium hydroxide or MTA

• Calcium hydroxide has been demonstrated to have long-term success, MTA results in more predictable dentin bridging and pulp health

• MTA (at least 1.5 millimeters thick) should cover the exposure and surrounding dentin, followed by a layer of light- cured resin-modified glass ionomer

Complete Pulpotomy

• Immature permanent teeth with carious pulp exposure → interim procedure to allow continued root development (apexogenesis)

• Emergency procedure for temporary relief of symptoms until a definitive root canal treatment can be accomplished

• Complete removal of the coronal vital pulp tissue

• Placement of a biologically acceptable material in the pulp chamber

• Restoration of the tooth

• Compared to traditionally-used calcium hydroxide, MTA and tricalcium silicate exhibit superior long-term seal and reparative dentin formation leading to a higher success rate

Apexogenesis

• Histological term → continued physiologic development and formation of the root’s apex

• Formation of the apex in vital young permanent teeth can be accomplished by implementing the appropriate vital pulp therapy

  • Indirect pulp treatment

  • Direct pulp capping

  • Partial pulpotomy for carious and traumatic exposures

Non-vital Pulp Therapy in Immature Permanent Teeth

1. Pulpectomy

2. Apexification

3. Regenerative Endodontics

Non-vital Pulp Therapy in Immature Permanent Teeth: Pulpectomy

• Restorable permanent tooth with closed apex that exhibits irreversible pulpitis or a necrotic pulp

• Entire roof of the pulp chamber removed → gain access to the canals and eliminate all coronal pulp tissue

• Following cleaning, disinfection, and shaping of the root canal system, obturation of the entire root canal accomplished with a biologically-acceptable semi-solid or solid filling material

Non-vital Pulp Therapy in Immature Permanent Teeth: Apexification

• Non-vital permanent teeth with incompletely formed roots

• Inducing root end closure by removing coronal and non-vital radicular tissue just short of the root end

• Biocompatible agent (ex. calcium hydroxide) placed in the canals for two weeks to one month to disinfect canal space

• Root end closure accomplished with apical barrier (ex. MTA)

• Gutta percha to fill remaining canal space

Non-vital Pulp Therapy in Immature Permanent Teeth: Regenerative Endodontics

• Definition: biologically based procedures designed to physiologically replace damaged tooth structure (dentin, root structures, pulp-dentin complex)

• Indication: nonvital permanent teeth with incompletely formed roots

• Goals:

  • Elimination of clinical symptoms/ signs and resolution of apical periodontitis in teeth with a necrotic pulp and immature apex

  • Thickening of the canal walls and/or continued root maturation is an additional goal

• Disinfected root canal space is filled with the host’s own vital tissue

Summary of Materials

• Pulpal liner or Indirect Pulp Treatment

  • Vitrebond (resin modified glass ionomer)

  • Ultra-Blend (calcium hydroxide in urethane dimethacrylate base)

• Direct Pulp Cap

  • Calcium Hydroxide (Dycal)

  • MTA

• Pulpotomy

  • MTA

  • Formocresol

• Pulpectomy

  • Vitapex

  • Kri-paste

• Base

  • Zinc Oxide Eugenol (ZOE)

  • Calcium sulfate and zinc oxide → Tempit

  • GI

  • RMGI

Calcium Hydroxide

• Mineralizing/bacteriostatic agent

• Alkaline pH → 12

• Caustic when placed against vital pulp tissue

  • Causes superficial necrosis

• Irritant quality

  • Stimulates development of calcific bridge → evident 1 month after placement

• Pulp beneath material remains vital and free of inflammation

MTA

• High biocompatibility

• Alkaline pH

• Induces dentin bridging

• Expensive (relative to cost of formocresol)

• Grey MTA → discoloration

• White MTA

Formocresol

• Fixative and bactericidal action

  • Does not promote healing

• Caustic to gingival tissues

• 1:5 concentration → Buckley’s formocresol

  • 1:5 dilution → equally good results with fewer post op complications than full strength

• Interim use in permanent teeth to be followed by conventional endodontic therapy (RCT)

• Concerns with toxicity

• Study

  • Purpose: determine presence of formocresol in plasma of children undergoing oral rehabilitation involving pulp therapy under general anesthesia

  • Method:

    • 30 children age 2-6 years

    • Preop, intra-op, & post-op peripheral venous samples collected

    • Samples analyzed for formaldehyde and cresol levels

  • Results/Conclusions:

    • 85 pulpotomies performed, 312 blood samples collected

    • Formaldehyde was undetectable above baseline and cresol was undetectable in all samples

    • Benzyl alcohol (byproduct of cresol metabolism) present in all samples except pre-op samples

      • Levels present far below FDA daily allowance

    • Unlikely that formocresol used in dose typical for vital pulpotomy poses any risk to children

Primary Pulpectomy Medicaments

• Vitapex – Iodoform and calcium hydroxide

  • Radiopaque

  • Antibacterial

  • Easy to use

• Kri Paste – Iodoform, parachlorophenol, camphormen

  • Bacteriocidal

  • Resorable

  • Less easy to use

Summary and Goals of Pulp Therapy

• Summary

  • Proper diagnosis is KEY

  • Consider:

    • Most conservative treatment

    • Treatment that offers best chance of long term success

    • Treatment with least risk of subsequent complications

  • Always weigh potential risk of failure

  • Monitor pulpal treatment regularly

    • Abnormal root resorption

    • Abscess

    • Early exfoliation or over retention

• Goals

  • Eliminate pain and infection

  • In vital teeth, maintain integrity and health of teeth and supporting tissue while maintaining vitality of pulp

  • In non-vital teeth, maintain integrity and health of supporting tissue, while retaining tooth to preserve form and function

  • Maintaining pulp vitality is a primary goal for treatment of young permanent dentition

  • In young permanent teeth with immature roots, the pulp is essential for continued apexogenesis

  • Long term retention of a permanent tooth requires favorable crown/root ratio and thick dentinal walls to withstand normal function