University of Jordan
Faculty of Dentistry
5th year (2015-2016)
Price & Date of printing:
Designed by: Hind Alabbadi
Pulp therapy of primary teeth
Aims of pulp therapy of primary teeth : to maintain integrity and health of primary teeth and supporting tissues .
The difference in primary teeth is that you have the option to take them out , because they will exfoliate at some point and will be replaced by permanent teeth , so you have to make a decision either to treat or extract based on the patient , dental history , dental status and medical status.
So in primary teeth you have the option to take it out or treat it based on several factors
But in general we prefer to treat and maintain the primary teeth although they are disposable because they are important in :
Digestion and assimilation of food
Maintaining a space for permanent teeth to erupt (so the best space maintainer is the primary tooth itself) , so we don't like to take them out before their natural time of exfoliation because space maintainers have many disadvantages like caries and food accumulation
helping the patient to get the best occlusion
Sometimes we prefer to take them out , for example if we have an infected primary molar with local infection , it will affect the underlying premolar especially in early stage of development , then development of turner tooth may occur . In this case you have 2 options either to take it out or do pulpectomy , but if we have a resorbed root we prefer to take it out
How to know when to extract primary teeth or not we have to do treatment planning
Treatment plan :
Any treatment plan should be based on a thorough history , examination and appropriate investigations. It should take in consideration patient's medical , dental and social status.
Any planned treatment should include consederation of :
the patient's medical history
the value of each involved tooth in relation to the child's overall development (for example , we aways prefer to keep E's as much as we can but D's sometimes we prefer to take them out)
alternatives to pulp treatment
restorability of the tooth
when you take the medical history it gives you the direction of treatment , if we have ..
patients at risk of extraction for severe disorders like hemophelia , every effort should be made to preserve the tooth and prevent extraction , any patient with bleeding disorders we prefer pulpectomy rather than extraction
immuno-compromised child who suffer from primary disease or treated by chemo-therapy or transplantation , we go for extraction rather than pulpoctomy to prevent the risk of residual infection
3. patients with congenital heart disease , we go for extraction
4. patients with diabetes that have a high susceptibility to infection , we go for extraction
So we always prefer to maintain the primary tooth , but when we have a risk of infection we have to extract it. So when the patient has a risk of infection
we go for extraction.
We have a number here which is 3 in the guidelines of society of amrican pediatric dentistry 2006 (minimal number of extensively carious primary molars teeth that require pulp therapy to go for treatment ) when the patient have more than 3 carious teeth the patient may not cooperate with us ….
Dental factors guide us to either take the tooth out or leave it :
general oral condition of the patient
if the patient has less than 3 of extensively carious primary molars that require pulp therapy , you can treat them all (the patient can tolerate up to 3 pulpotomies , if more than 3 they go for extraction) we try to preserve E's and extract D's .
it's not a rule , but in general when you find a patient with 8 carious molars , it is very difficult to do pulpotomy for this 8 molars
if we have hypodontia ( most probably missing of lower second premolar) we have to treat the tooth and preserve it as much as possible , and we go for pulpoctomy rather than pulpotomy
tooth itself might guide you to what you should do , if the tooth is not erupted we prefer to keep it and do pulp treatment rather than take it out
if the tooth is not restorable we go for extraction
if we have internal root resorption on x-ray in primary teeth , we go for extraction
large number of extensive caries involving pulp (more than 3) , we go for extraction
if the roots of primary tooth are resorbed (about 2/3 of the root is resorbed) and it's symptomatic , and it is near exofoliation , we go for extraction rather than try to keep it there
balancing extraction , if we extract first primary molar we can put a space maintainer on that side or take the other first primary molar out to balance this out , we do this balancing extraction in C's & D's , but don't do it in E's
extensive pathology of acute facial swelling that necessitates emergency admission like cellulites , it should be extracted
If the patient is :
positive parental attitude
we go for pulp treatment (pulpetomy or pulpectomy) and we know they'll comeback for review
If the patient is :
unfavorable parental attitude
and the patient won't come back so we go for extraction
clinical diagnosis is derived from :
comprehensive medical history
review of past and present dental history and treatment including current symptoms and chief complain
evaluation of the area associated with chief complain by questioning the child and parents , we start with the child but also we need to ask parents because their description is more clear than the child's description.
Ask about location , intensity , duration , stimulus , relief and spontaneity of the pain .
we talk to the child to obtain a rapport but you have to talk to the parents to get the state of the pain
extra oral examination as well as intra oral examination soft and hard tissues
radiographs , most of time if you suspect pulpal involvement you would go for apical x-ray rather than bitewing x-ray
clinical test such as : palpation , percussion and mobility
Taking history :
Taking a good history is important , you talk to the child first , then get more details from parents
If they are coming in pain , you need to take a good history of pain , it will guide you towards what you to do for the involved tooth ..
history and characteristic of pain are important in determining whether the tooth pulp is treatable or not
selection of appropriate treatment for the tooth is essential in its long time prognosis
ex. if the tooth required puplectomy and we do a pulpotomy , we might get rid of the immediate symptoms (the pain will relief for a certain period of time , but actually it’s not the
appropriate treatment in this case) so mostly after a month , the patient will come back with a failure of pulpotomy , abscess will develop and u will end by puplectomy which was the approptiate treatment from the beginning
presence or absence of history of pain is not as reliable as in permanent teeth
degeneration of primary pulp even to the point of abscess formation without the child recording pain is very common
It's hard to explain .. why ?! :
children interpret pain differently than adults.
children may be distracted by their high level of activity , and they go complaining to their parents from the pain too late
children have been shown to be a poor historians when reporting the severity of the pain
children aren’t good at describing subjective symptoms of pain and if the dentist ask the child a leading question, false positive and false negative results may occur ..
most of the time, children try to guess and let u hear what u want to hear , and it might be false negative or false positive , So we don’t always depend on their description and we should ask the parents about the symptoms that the child had suffered from .
History of pain :
toothache at meals or immediately after, may not indicate extensive pulpal pathology , It could be due to food accumulation in a carious lesion (pressure) or due to chemical irritation of food over a carious lesion , so if it is only associated with meal time most probably there will be no extensive pulpal pathology
momentary pain which disappears on removal of stimulus i.e. following thermal stimulation, indicates that pathology is limited to the pulp chamber.
if pathology is limited to the pulp chamber we can do pulpotomy , if the pathology is extended to the radicular area we go for pulpoctomy or extraction
Reversible pulpitis is a provoked pain by thermal, chemical and mechanical irritants and once the causative irritants are removed, the pain theoretically ceases.
teeth exhibiting provoked pain (not spontaneous) of short duration (doesn't last for long time) , relived with over the counter analgesics , or by brushing or upon the removal of the stimulus and without signs & symptoms of irreversible pulpitis , have clinical diagnosis of reversible pulpitis and are candidate for vital pulp therapy (indirect pulp treatment , direct pup cap or vital pulpotomy)
teeth diagnosis with a normal pulp, requiring pulp therapy or with reversible pulpitis should be treated with vital pulp procedures (indirect pulp therapy , direct pulp cap ,pulpotomy )
A (spontaneous pain) sever toothache at night and the child can't sleep , indicate extensive degeneration in the pulp and the pathology extends to the radicular area (so it's irreversible pulpitis) , so we go for pulpoctomy or extraction
spontaneous toothache of more than momentary duration occurring at any time means that pulpal disease has progressed too far for treatment with a pulpotomy ( pulpectomy or extraction )
spontaneous or irreversible pulpitis is a constant or throbbing pain without stimulation and may last a long time even after the causative irritants are removed.
Spontaneous or irreversible pulpitis is associated with extensive degenerative changes extending in the root canal if pulpotomy is not indicated
So in general if the child can't sleep at night , we don't go for pulpotomy , we go either for (pulpoctomy or extraction)
Clinical examination :
Careful interaoral and extraoral examination is essential in arriving to the correct diagnosis.
Cellulitis due to an infected primary tooth indicates that this tooth is non-vital.
most of the time we will go for extraction.
If we see an abscess or draining fistula it's either a puplectomy or extraction.
How can we tell if the abscess is from E or D ? by vitality test , x-ray or using the probe very gently to check for mobility , try not to use percussion
An access of fistula in primary molar presents in inter radicular area
Fistula clinically will present at the junction of attached gingiva and the alveolar bone , Options of treatment in that case are either pupoctomy or extraction , not vital pulp therapy depending on patient and the tooth itself .
pulpal inflammation in primary molars precedes its exposure.
most primary molars where caries had involved more than half of the intercuspal distance, manifested pulp inflammation involving the entire pulp horn, but rarely the root canals tissue and it's the ideal indication of vital pulp therapy.(pulpotomy)
in the past they rely on a rule that said (if you see a broken marginal ridge , go for pulpotomy) , most of the time in D's that could be the case , because in the broken marginal ridges at least the pulp horn adjacent to the carious area will be affected and extensive inflammation in the pulp may occur even if u do a regular filling it will fail
Nowadays, the approach has been improved toward indirect pulp therapy rather than pulpotomy
Usually in class 2 especially in D's when they are extensive , it will require more invasive treatment
E's if we have occlusal caries , usually the choice will be indirect pulp therapy
Inflammation of the pulp in primary molars develops at early stage of proximal carious attacks, and by most of the proximal caries, is manifested clinically the pulp inflammation is quite advanced.
Abnormal tooth mobility is another clinical signs that may indicate a severely diseased pulp.
When such a tooth is evaluated for the mobility, manipulation may cause the child to feel pain, so be gentle (to check for mobility use the probe very gently)
Sometimes pain is absent even with advanced mobility, this means that the pulp is in more advanced and chronic degenerative condition
pathological mobility must be distinguished from normal mobility in primary teeth near exfoliation , we start by comparing with the contralateral tooth , most of the time they have equal level of mobility we have to take an x-ray .
sensitivity to percussion or pressure is a clinical symptom , suggest an inflammation that has progressed to involve the periodontal ligaments.
Care should be taking in interpreting the results, as the children give a lot of false positive (they are very sensitive)
In children, do a gentle percussion with the tip of finger and not with mirror handle
We don't use electric pulp test in primary molars because it leads to false positive results .
Radiographic examination :
Preoperative radiographs are a must before pulp therapy.
It provides important information that will affect the diagnosis and treatment modalities.
So we don't go ahead for any treatment before taking x-rays
most of time we need periapical x-rays
Periapical radiograph provide necessary details for the tooth and the surrounding structures
Bitewing radiographs may also be requested
But always you get a better details and underlying successor with periapical radiograph to decide if pulp therapy is necessary or not.
A radiograph may be misleading (taken too early) if it doesn't show he intra-radicular lesion when it might be present histologically (the patient is complaining from symptoms of irreversible pulpitis) but hasn't develop sufficiently to be shown in radiograph.
faulty radiograph is more in upper arch due to the superimposition of the permanent successor, the appearance of intar-radicular area may be masked in that case and you have to take a supplemental bitewing radiograph to show details more clearly.
In general radiograph interpretation is more difficult in children than in adults.
The roots of primary teeth undergoing even normal physiological resorption often present a misleading picture or one suggestive of pathological change.
The proximity of the carious lesion to the pulp can't always be accurately determined from the radiograph . What often appears to be an intact barrier of secondary dentin protecting the pulp may be actually a perforated mass, irregular calcified and carious materials , so we try to treat the tooth because the pulp near that area may develop extensive inflammation
Internal resorption (which is an incidental finding), usually indicates chronic inflammation and the activity of giant cells causing resorption of the dentin.
Internal resoroation creates few symptoms and usually detected as an incidental finding in radiographic examination and should be considered as a form of irreversible pulpitis, usually we extract the tooth and place space maintainer in such cases.
Therefore the dentist needs to correct the comprehensive information based on medical history , dental history , history of pain , Radiographic findings , clinical examination , pulp test deliver the successful pulp therapy ,but we always have failure rate .
Now we'll talk about different modalities of vital pulp therapy for primary teeth diagnosed with normal pulp or reversible pulpitis : ( not irreversible puplitis)
Before we start we have to know that we should work under rubber dam orher wise we have to put suction and cotton rolls on both buccal and lingual sides of the tooth because it'll affect the prognosis of the treatment .
options of management:
Indirect pulp treatment
Direct pulp cap
1- Protective liner
A protective liner is a thinly-applied liquid placed on the pulpal
surface of a deep cavity preparation, covering exposed dentine
tubules, to act as a protective barrier between the restorative
material or cement and the pulp
when you feel that you have deep cavity you can use the protective liner, you remove all the caries then you end up very close to the pulp so you put the protective liner, examples of protective liners:
Dentine bonding agent
Placement of a thin protective liner is at the discretion of the
clinician ( each one should know if he\she needs to put the protective liner or not )
In a tooth with a normal pulp, when all caries are removed for a
restoration, a protective liner may be placed in the deep areas of the
preparation then we put the filling material.
Objectives of the protective liner:
To preserve the tooth’s vitality, promote pulp tissue healing and
tertiary dentine formation, and minimize bacterial micro-leakage
Ideally adverse post-treatment clinical signs or symptoms such as
sensitivity, pain, or swelling should not occur
-indirect pulp treatment
Indirect pulp treatment is a procedure performed in a tooth with a
deep carious lesion approximating the pulp but without signs or
symptoms of pulp degeneration (the patient has deep caries but he is not complaining of signs and symptoms of pulp condition, he feels pain at meal times but this pain is alleviated by brushing in this case we go for indirect pulp capping)
The pulp is judged by clinical and radiographic criteria to be vital
and able to heal from the carious insult
the idea from using indirect pulp capping is:
To arrest the carious process and provide conditions that help the*
formation of reactionary dentine beneath the stained dentine and remineralization of the remaining carious dentine
*To promote pulpal healing and preserve the vitality of pulp tissue
1-Removal of all caries at the enamel-dentine junction (all walls are clean ) then we remove the caries lying directly over the pulp region and this removal is judicious, which means that we judge to remove or not to avoid pulp exposure, then we remove caries until we feel that we are so close to the pulp and exposure might happen then we stop. So the caries surrounding the pulp is left in place to avoid pulp exposure
2-Placement of appropriate lining material to promote healing and repair .
3-Definitive restoration to achieve optimum external coronal seal
(ideally a stainless steel crown, it is the best to achieve coronal seal)
Examples of lining materials
Glass ionomer cement
The use of glass ionomer cements or reinforced zinc
oxide/eugenol restorative materials has the additional advantage
of inhibitory activity against cariogenic bacteria
there are 2 techniques to do indirect pulp treatment:
1- ART (atraumatic restorative technique): it is a technique of removing tooth decay with hand instruments, and restoring the cavity with adhesive restorative material, most of the time we use glass ionomer
Atraumatic/alternative restorative technique (ART) has been
endorsed by the World Health Organization as a means of
restoring and preventing caries in populations with little access
to traditional dental care (used in community dentistry, outside the clinics) Because circumstances do not allow for follow-up care, ART mistakenly
has been interpreted as a definitive restoration.
2- ITR interim therapeutic restorations utilizes similar techniques but has different therapeutic goals.
ITR may be used to restore and prevent carious lesions in very
young patients, uncooperative patients, or patients with special
health care needs,(when you have patient with multiple carious teeth it’s helpful to excavate caries and to put glass ionomer (ITR) but this is just temporizing to relieve symptoms, to decrease bacteria … then we go for definitive restorations) or when traditional cavity preparation and
or placement of traditional dental restorations are not feasible
and need to be postponed.
Additionally, ITR may be used for step-wise excavation in children with multiple open carious lesions prior to definitive restoration of the teeth (the patient is cooperative but has multiple open caries then ITR is useful here)
also ITR may be used in erupting molars when isolation conditions are not optimal for a definitive restoration ( if there is partially erupted 6 with poor oral hygiene we can't put composite so we excavate and put glass ionomer until the full eruption of the molar) or in patients with active lesions prior to
treatment performed under general anesthesia
The use of ITR has been shown to reduce the levels of cariogenic oral
bacteria (eg, mutans streptococci, lactobacilli) in the oral cavity
immediately following its placement. However, this level may
return to pretreatment counts over a period of six months after
ITR placement if no other treatment is provided
It's mostly successful in class 1 caries on E,s more than D,s
How do you do it?
The ITR procedure involves removal of caries using hand instrument(excavator)
or rotary instruments with caution not to expose the pulp.
Leakage of the restoration can be minimized with maximum
caries removal from the periphery of the lesion. Following
preparation, the tooth is restored with an adhesive restorative
material such as glass ionomer or resin-modified glass ionomer
ITR has the greatest success when applied to single
surface or small two surface restorations (in small cavities and in E,s more than D,s especially if there is already broken marginal ridge)
Inadequate cavity preparation with subsequent lack of retention and insufficient bulk can lead to failure. Follow-up care with topical fluorides and oral hygiene instruction may improve the treatment
outcome in high caries-risk dental populations, especially when
glass ionomers (which have fluoride releasing and recharging
properties) are used.
Some authors have recommended that indirect pulp treatment can be
undertaken as a two-stage procedure
Initial caries removal is achieved without the use of local
anesthetic and a reinforced zinc oxide eugenol or glass ionomer
cement restoration is placed (preferably GI cement)
After 1–3 months further caries removal is carried out under local
No precise method has been developed to determine how much
caries to remove; it is reliant on good clinical judgment
(some dentists recall the patient after 3 months, they give local anesthesia and they remove the GI and clean the caries then they put the final restoration (ideally stainless steal crown) )→this is the two stage procedure .
Other investigators have reported a higher success rate when
indirect pulp treatment is performed as a single visit procedure
(they remove caries as much as they can from the walls and the pulpal floor and then they put GI filling and stainless steal crown and that’s it ) → one stage procedure, so no need to go in another time to avoid pulp exposure
Current literature indicates that there is inconclusive evidence
that it is necessary to reenter the tooth to remove the residual
Several studies have reported success rates (an absence of
symptoms or pathology) of over 90% at 3 years follow-up
Success appears to be greater in second primary molars than first
Indirect pulp capping has been shown to have a higher success
rate than pulpotomy in long term studies .
It also allows for a normal exfoliation time ( one of the disadvantages of the pulpotomized tooth is the resorption even if there is no symptoms then we might lose the tooth early on and then you need a space maintainer
Therefore, indirect pulp treatment is preferable to a pulpotomy
when the pulp is normal or has a diagnosis of reversible pulpitis
The success of the technique appears to be highly dependent on
achieving a good external coronal seal, which will effectively cut
off the nutritional supply for any remaining dentinal bacteria and
will prevent further bacterial micro-leakage (it's very important to seal it using ss crown)
It has been shown that failure is 7.7 times more likely in a tooth
restored with an amalgam than one restored with a preformed
Adhesive restorations have also been shown to provide optimum
protection from marginal leakage in pulpotomised primary molars (if we couldn’t put ss crown or if the tooth is about to exfoliate we can put adhesive restorations like composite) .
Sorry for any mistakes