Chapter 4: Pediatric Dentistry Introduction



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Section F: Pulp Therapy and Trauma in the Primary Dentition

Introduction


Just as in the permanent dentition, primary teeth are subject to the insults of trauma and dental caries. In the primary and mixed dentition, premature loss of primary teeth can lead to:

  • loss of function

  • compromised esthetics

  • space loss with subsequent orthodontic complications

For these reasons pulp therapy in the primary dentition is often a consideration.

Diagnosis and Treatment Planning for Pulp Disease

Introduction


Before a primary tooth with a compromised pulp is treated, an evaluation of the pulpal health must be done. A thorough clinical and radiographic evaluation should be completed to search for any sign of necrosis or breakdown of the supporting structure. Symptoms associated with the tooth should be evaluated for clues to vitality. Thermal and electric testing are unreliable in the primary dentition.

A young child may not be able to give an accurate description of the discomfort. All diagnostic information must be taken into consideration before making a final diagnosis.



Note: Profound anesthesia and rubber dam isolation are assumed. All primary teeth receiving pulp therapy should be restored with a full coverage restoration.

Reversible Pulp Disease


A history of provoked pain, either from mastication or from thermal insult, is more indicative of reversible pulp disease, which would indicate more conservative care i.e., indirect pulp cap or pulpotomy.

Irreversible Pulp Disease


A history of spontaneous pain in a primary tooth is indicative of irreversible pulp disease, and treatment could be either:

  • extraction

  • pulpotomy

Contraindications


Pulp therapy is not indicated in the following situations:

  • Teeth that are non-restorable due to caries

  • Teeth with root resorption, although temporary maintenance for space concerns may be considered.

  • Severe space loss has occurred due to excessive interproximal caries (It may be preferable to extract a primary tooth and consider space maintenance.)

  • Immunocompromised patients

Performing an Indirect Pulp Cap

Introduction


Deep caries can provoke symptoms without a carious exposure. An indirect pulp cap can preserve the integrity of the pulp. Recent literature and clinical experience, attests to the success of this technique. However, failure of an indirect pulp cap is often seen on primary first molars.

Indications


The following are indications for an indirect pulp cap:

  • a tooth with deep caries that is asymptomatic or only exhibits provoked pain

  • a tooth with deep caries, no signs of pulp disease, and without pulp exposure.

Contraindications


The following are contraindications for indirect pulp cap:

  • a tooth with deep caries and a history of spontaneous pain

  • a tooth with frank carious or mechanical pulp exposure

  • clinical or radiographic signs of infection, necrosis, or resorption

Procedures for Performing Indirect Pulp Therapy


The following procedure is used for performing indirect pulp therapy in the primary dentition

Step

Action

1

Rubber dam isolation

2

Remove decay down to a shallow layer of semi-hard, affected dentin overlaying the

pulp.


3

Place a protective CaOH2 or ZOE base over the remaining carious dentin.

4

Restore the tooth sealing the dentin from the oral environment with a full coverage restoration.

Direct Pulp Therapy


Direct pulp capping in primary teeth is appropriate only in extremely limited conditions. Minute exposures due to trauma or non-carious mechanical exposures may respond to a direct pulp cap with a CaOH2 material. Generally, a vital pulpotomy is preferred due to its higher rate of success.

Performing a Vital Pulpotomy

Introduction


In a vital pulpotomy, the coronal pulp is removed, the pulp stumps treated, and the chamber is filled with a sedative dressing. Use of this technique assumes the following:

  • Only the coronal portion of the pulp is affected.

  • The radicular pulp is preserved.

  • The support structures remain unaffected.

Indications

A vital pulpotomy is indicated when there are small carious exposures with vital radicular pulp. The tooth exhibits reversible pulpitis symptoms.

Contraindications

A vital pulpotomy is contraindicated in the following situations:



  • symptoms of irreversible or hyperemic pulp disease

  • teeth close to exfoliation or that are non-restorable

  • clinical or radiographic signs of infection, necrosis, or resorption

Procedures for Performing a Vital Pulpotomy

The following steps should be used to perform a vital pulpotomy in the primary dentition:



Step

Action

1

Isolate with rubber dam. Perform occlusal reduction. Remove caries.

2

Expose the coronal pulp by removing the roof of the pulp chamber with a high-speed handpiece

3

Amputate the pulp and remove any remaining pulp tissue from the floor of the chamber using a slow-speed handpiece with a round bur or a sharp spoon excavator.

4

Perform a ferric sulfate or formocresol pulpotomy.

5

Place a ZOE dressing in the chamber. Restore appropriately.




  • Alternative pulpotomy techniques (e.g., electrocautery, or glutaraldehyde) have been advocated. Contact a pediatric dentistry consultant for more information.

  • The formocresol pulpotomy techniques uses a 1:5 dilution of Buckley’s fromocresol on a dampened cotton pellet.
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