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ISD4 Pulp Therapy for Primary Molars
How to manage extensive caries in posterior primary teeth
AIM
To identify the rationale and techniques for restoring the extensively carious primary dentition
LEARNING OUTCOMES
To discuss restorative techniques for primary teeth with extensive caries
To understand how to manage the pulp in primary teeth with extensive caries
To learn the technique of vital pulp therapy (pulpotomy) on a primary molar in preparation for your OSS session
What is Pulp Therapy?
Pulp therapy is the management of the pulp tissues of primary or permanent teeth and in the loosest terms covers everything from protecting an affected pulp to root canal therapy.
In the context of primary teeth, it is an umbrella term which includes:
indirect pulp capping
direct pulp capping
vital pulpotomy
pulpectomy
Pulp therapy in the primary dentition is within the Scope of Practice for dental therapists and dentists.
Dental Caries in the Primary Dentition
Management of a grossly carious primary molar is a challenging but common aspect of dental care for young children. You have covered the principles of minimally invasive dentistry and the biological management of caries in CLC2.
This Sway aims to reinforce this knowledge and to introduce the concept of pulp therapy in primary teeth.
We will specifically discuss the management of extensive caries in primary molars using this resource.
Things to consider:
As a clinician, you need to be competent and confident in selecting the correct method of treatment.
Ensure you understand the disease process and why we choose each method of treatment.
Primary Molar Caries - Things to Consider
Primary molars undergo rapid caries progression when subject to a cariogenic diet and poor oral hygiene
Primary molar morphology is susceptible to caries progression and loss of vitality because of the following features
Wide approximal contact areas
Large pulp chamber compared to permanent teeth
Thinner enamel
Caries can progress rapidly in an unfavourable environment and will also involve the pulp quickly
Primary molars may undergo irreversible pathological changes before pulp exposure
Bifurcation radiolucencies on radiographs are a sign of pulpal infection
How to Diagnose Pulpal Involvement in Primary Teeth
It is important you are competent in diagnosing the pulp status of any carious tooth. In primary teeth consider the following:
Pain history
The following symptoms and clinical signs are likely to be associated with significant pulpal inflammation and pathology
The patient reports spontaneous pain - especially at night
Reported pain on biting
Analgesics required to relieve pain
Clinical Signs on Examination
The clinical extent of caries
Marginal ridge breakdown- closely associated with caries involving the pulp
Intra-oral swelling or sinus
Extra-oral swelling (infection can spread rapidly to become life-threatening- revise signs of spreading infection in adults and children)
Special investigations
Gentle finger pressure - Determine if the tooth is mobile or tender to percussion
No pulpal sensibility tests recommended - unreliable in primary dentition
Radiographs are mandatory as they give vital information such as:
The extent of caries, proximity to the pulp
Presence of pathological or physiological root resorption
Presence of a permanent successor
Why Would We Want to Keep Primary Molars with Extensive Caries?
Medical factors
Patients at higher risk from extraction: bleeding disorders, hereditary angiooedema
Patients at higher risk from general anaesthesia for dental extraction: some cardiac conditions, cystic fibrosis
Tooth factors
Solitary or minimal teeth with extensive caries
Hypodontia of the permanent dentition
To prevent mesial migration of the first permanent molars
Iatrogenic pulpal exposure during caries removal (much less likely with current techniques of minimally invasive caries removal and hall technique preformed metal crowns)
Social factors
Good compliance, regular attendee, parents positive about treatment
When to Extract Instead?
Medical factors
Patients at a higher risk of residual infection: immuno-compromised, susceptible to infective endocarditis
Tooth factors
Tooth unrestorable after pulp therapy
Extensive internal root resorption
A large number of teeth with likely pulpal involvement
Tooth close to exfoliation
Extensive pathology or acute facial swelling necessitating hospital admission
Social factors
Poor compliance, irregular attendance, negative parental attitude to treatment
What are Our Options?
Firstly diagnose if the pulp is likely to be vital or non-vital (or soon to be non-vital!)
Clinically this means we are trying to decide if the pulp is:
1. normal or has reversible pulpitis ( a vital pulp capable of healing)
OR
2. Is necrotic or has irreversible pulpitis ( a vital pulp not capable of healing)
Signs of normal pulp
Asymptomatic (no previous history of pain or swelling)
No mobility or pain on occlusal pressure
No clinical or radiographic signs of radicular infection or abscess
What are our options?
Firstly diagnose if the pulp is likely to be vital or non-vital (or soon to be non-vital!)
Clinically this means we are trying to decide if the pulp is:
1. normal or has reversible pulpitis ( a vital pulp capable of healing)
OR
2. Is necrotic or has irreversible pulpitis ( a vital pulp not capable of healing)
Signs of the normal pulp
Asymptomatic (no previous history of pain or swelling)
No mobility or pain on occlusal pressure
No clinical or radiographic signs of radicular infection or abscess
Signs of a vital pulp capable of healing
History of short-duration pain relieved by OTC painkillers or removal of a stimulus
No mobility or pain on occlusal pressure
No signs or symptoms of irreversible pulpitis or radicular infection or abscess.
Signs of a vital pulp not capable of healing or necrosis
History of spontaneous or unprovoked pain
Sinus tract/abscess
Mobility
Furcational/apical radiolucency on radiographs
Internal/external resorption on radiographs
Pulp is Vital or Capable of Recovery
INDIRECT PULP TREATMENT -
A technique whereby caries removal, especially at the base of the cavity is incomplete to avoid pulpal exposure. The focus is on sealing in caries to maintain vitality.
A good seal is imperative!
This is the biological method of carious management you have been taught.
Hall technique preformed metal crowns and caries sealed in by restorations are both examples.
This technique is only suitable for a tooth free of signs or symptoms of pulpal pathology.
DIRECT PULP CAP
It is not generally recommended in the primary dentition.
This technique involves the complete removal of caries and covering of exposed pulp tissue with bio-ceramic material (e.g Biodentine/ MTA)
As we have other less invasive viable options such as Hall technique PMC, indirect pulp capping and stepwise caries removal this technique is included only for background understanding.
VITAL PULPOTOMY
Removal of infected coronal pulp tissues with an aim to maintain pulp vitality.
Only in teeth with extensive caries but without evidence of radicular pathology.
Post pulpotomy seal is very important. Restore with PMC or excellent composite restoration.
Pulp is Non Vital or Not Capable of Recovery
PULPECTOMY- removal of coronal and radicular pulp tissues (same principle as RCT in permanent teeth)
EXTRACTION - You should know about this!
Indirect Pulp Treatment
AIMS
To arrest the carious process
To maintain pulp vitality
CASE SELECTION
Tooth deemed restorable
Could be a cavitated or non cavitated class 1 or class 2 lesion
Band of sound dentine between the lesion and the pulp on a radiograph
No pulpal involvement
No irreversible pulpitis
CLINICAL OUTCOME
90% clinical success
Good acceptance for patients, parents and dentists
Aid alignment of permanent dentition
For cases like this we would usually place a Preformed Metal Crown using the Hall Technique or high quality composite restoration after treatment.
Direct Pulp Treatment
Aim
To preserve the vitality of remaining pulp and achieve reparative dentine formation over the exposed site
Case selection
Direct pulp capping in primary molars is not recommended for carious pulp exposures unless the tooth is close to exfoliation
In primary molars only indicated for traumatic/iatrogenic exposures
Not recommended as a technique by BSPD
Clinical outcomes
Calcium Hydroxide has been shown to have poor success rates and some reports of internal resorption
Studies have shown that using bioceramic materials such as MTA for a carious exposure direct pulp cap, has clinical success at 18 months follow-up
Vital Pulpotomy
Aim
Removal of irreversibly inflamed coronal pulp and maintenance of healthy or reversibly inflamed radicular pulp
Case selection
Carious exposure of vital coronal pulp tissue
No periapical periodontitis or sepsis
Clinical outcomes
>90% clinical and radiographic success at 36 months
Clinical Stages of Pulpotomy
https://liverpool.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=088a69db-70eb-4c88-bc70-acaa00b934f4
Pulpotomy Clincal Technique Stages
Successful removal of inflamed coronal pulp tissue = pulp stumps bright red and good haemostasis after 3-5 mins
Unsuccessful removal of inflamed coronal pulp tissue = deep crimson colour and continued bleeding after 3-5 mins
If when accessing the pulp chamber there is NO pulpal tissue or bleeding, a pulpotomy is not indicated. A non-vital pulpectomy or extraction is required instead
Pulpotomy Clinical Technique Completion
How to Restore After a Pulpotomy
It is imperative that a good coronal seal is achieved when undertaking a pulpotomy. Bacterial ingress is likely to result in failure.
Preformed metal crowns are the restoration of choice although an excellent composite placed under a rubber dam is a viable alternative.
To prevent occlusal interference after pulpotomy a more traditional PMC placement is indicated.
SSC Technique:
LA is required (as dentine will likely be cut)
Measure the initial canine relationship in maximum intercuspal position and record this in the notes
Reduce the occlusal surface by 1-1.5mm
Cut depth gauges on the occlusal surface first to aid this
Join them together
Instruct patient to close their teeth together to ensure they have sufficient clearance
Insert a periodontal probe into the occlusal clearance to check
If the rubber dam is in situ, it is often not possible to get the patient to close their mouth so gauge this yourself visually
Assess contact points to assess if space is required for seating the crown
The tooth may need preparation to reduce contact points
Dry the tooth and assess for adequate preparation
Use a periodontal probe to measure the mesiodistal width between the adjacent contact points and use this to aid in the selection of the crown size
The crown should fit easily over the tooth (no spring back)
Ensure airway protection of the patient while trying it in
Rehearse the path of insertion
Load crown with GIC to around 1-2 thirds of the capacity
Use a flat plastic to ensure the internal surfaces are covered
Dry and isolate the tooth
Ensure moisture control
Place the crown on the tooth from a lingual to buccal direction
Apply firm pressure
Quickly remove any excess cement with a cotton wool roll and remove the lingual cotton wool roll
Keep pressure on the crown for a further 60 seconds
Remove the cotton wool roll and Elastoplast
Use a periodontal probe to ensure no excess cement is present in the gingival sulcus
Gently floss the contact points
Surrounding gingiva should blanch slightly
Measure the overlap at the canines and record any increase in the occlusal vertical dimension (approximately 2mm likely)
Advise the patient that the crown will feel high in the bite but that this will resolve in approximately 2 weeks
Pulpotomy Follow Up
Radicular pulp should remain asymptomatic without adverse clinical signs or symptoms
Absence of any abscess or draining sinus
No excessive mobility or tenderness
There should be no radiographic evidence of external root resorption
Internal root resorption may be self-limiting and stable (monitor)
If resorption causes perforation/loss of supportive bone and/or clinical signs of infection/inflammation need to extract
MTA - Mineral Trioxide Aggregate - Things to Know
Constituents include; tricalcium silicate, dicalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite, calcium sulphate and bismuth oxide
pH 12.5
Hydrophilic (definitive restoration with PMC best)
Biocompatible
Direct bone apposition
Inductive effect on cementoblasts
Actively promotes hard tissue formation
Facilitates regeneration of PDL
Marginal seal
Mixed with sterile water to a sandy consistency and gently packed against radicular pulp stumps
Takes 4 hours to set completely
Treatment for Non Vital Primary Teeth
Pulpectomy:
RATIONALE
To remove irreversibly inflamed / necrotic pulp tissue (RCT)
Clean and irrigate the root canals
OBTURATE with a filling material that will resorb at the same rate as the primary tooth
CASE SELECTION
Irreversible pulpitis symptoms +/- clinical findings ( eg profuse haemorrhage following pulpectomy)
Non vital radicular pulp
Good patient compliance
Missing permanent successor and greater need to retain primary molar
Patient MH means we need to avoid extraction
Complicating Factors of a Pulpectomy
Only suitable in a handful of cases
Primary molar radicular morphology can be unpredictable
Physiological root resorption is not present or only minimally
Proximity to a permanent successor when instrumenting root canals
Need for excellent patient cooperation for success
Clinical outcome 86% at 36 months
Follow Up of All Pulp Treated Primary Teeth
6 Monthly recall until exfoliation
Clinical failure
pathological mobility
fistula / chronic sinus
pain
Radiographic failure
increased radiolucency
internal / external resorption
furcation bone loss
Summary
It is very important to understand the pulp and it's response to caries
Make sure you can identify whether a tooth is suitable or not for pulp therapy
Pulp therapies in primary molars have good prognosis when performed well- Learn your techniques.
Footnote
A pulpotomy is also indicated for traumatised permanent incisors, which have a complicated enamel-dentine fracture.
Rationale is still the same to remove affected tissue to maintain healthy pulp tissue underneath by maintaining vitality of radicular pulp to allow for completion of root development in immature teeth.
In literature is called a PARTIAL or CVEK PULPOTOMY
There is increasing evidence that vital pulpotomies in carious permanent teeth are a viable treatment option.
Please revisit your dentine-pulp complex lecture if you would like to learn about this in greater depth