Vital pulp therapy for the primary teeth

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Vital pulp therapy for the primary teeth

Rationale of pulp therapy

The primary objective of pulp therapy is to maintain the integrity and

health of the teeth and their supporting tissues
Any planned treatment should include consideration of*

  • The patient’s medical history

  • The value of each involved tooth in relation to the child’s overall


  • Alternatives to pulp treatment

  • Restorability of the tooth

  • Isolation:

  • it's the most important point for the success of the pulp therapy

  • ideally everything should be done under rubber dam, we don't do that but we can actually achieve a good isolation by using suction and cotton roll, if there is any contamination then the treatment will fail even if it was done properly

  • It is recommended that all pulp therapy be performed with

rubber-dam or other equally effective isolation to minimize

bacterial contamination of the treatment site

Vital pulp therapy for primary teeth diagnosed with a normal pulp or

reversible pulpitis (not irreversible puplitis) →options of management:

  • Protective liner

  • Indirect pulp treatment

  • Direct pulp cap

  • Pulpotomy

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:

  1. Calcium hydroxide

  2. Dentine bonding agent

  3. Glass ionomer

  • 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.→this is indication to use the protective liner.

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.

2-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

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

    • Dentine bonding agent

    • Resin modified glass ionomer

    • Calcium hydroxide

    • Zinc oxide/eugenol

    • 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 economic 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

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 pt 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 fluor-

ides 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 pt 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 ss 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

Clinical Outcome

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

primary molars

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

metal crown

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)
3- direct pulp treatment :
Indications: This procedure is indicated in a primary tooth with a

normal pulp following a small mechanical or traumatic exposure

when conditions for a favorable response are optimal.
Direct pulp capping of a carious pulp exposure in a primary tooth is not


A biocompatible radiopaque base such as mineral trioxide

aggregate (MTA) or calcium hydroxide may be placed in contact

with the exposed pulp tissue

The tooth is restored with a material that seals the tooth from

No long-term outcome data are available but prognosis is

reported to be generally poor, with some studies reporting a high

incidence of internal resorption

Further studies are required before such a technique is universally

Recommended ( if you have pulp exposure in primary tooth you go ahead and do pulpotomy, you don't do direct pulp capping)
A pulpotomy is performed in a primary tooth with extensive caries

but without evidence of radicular pathology when caries removal

results in a carious or mechanical pulp exposure

the same indications for indirect pulp cap : vital tooth, symptoms of reversible pulpitis (not irreversible pulpitits) the difference is the tooth condition itself , if it has extensive class2 for example or if it is the D ;) most of the time you do pulpotomy, but if it's class 1 or it is the E and there is no symptoms then you do indirect pulp capping

The coronal pulp is amputated, and the remaining vital radicular

pulp tissue surface is treated with a long-term clinically-successful


To remove the coronal pulp, which has been clinically diagnosed

as irreversibly inflamed, leaving behind a possibly healthy or

reversibly inflamed radicular pulp

the remaining vital radicular pulp (pulp stumps) can then be treated using several medicaments prior to replacement of the final restoration which is ss crown


      • 20% Buckley’s formocresol solution

      • 15.5% ferric sulphate solution

      • MTA paste

      • Pure calcium hydroxide powder

  • Sodium hypochloride

  • Gluteraldehyde

      • Electrosurgery

      • Laser

      • Enriched collagen solution

    • Formocresol

Sweet (1930), introduced the multiple -visit formocresol

Technique (they put formocresol and TF then after 1 week they remove the formocresol then they put the base and the ss crown)

The aim was complete mummification

Nowadays a five-minutes formocresol protocol is recommended (3-5 minutes)
Formocresol constituents:
19% Formaldehyde

35% cresol

15% Glycerol with 31% water

in 5 dilution of Buckley’s formocresol solution has been found to 1

be just as effective (there is no need to use the full strength, you can dilute it , it's the same effect)
High clinical success rates

Releases formaldehyde which diffuses through the pulp fixating

the tissue

Does not promote pulp healing (compared to ferric sulfate and MTA)

Concerns about the safety of formocresol have been appearing in

the dental and medical literature for more than 20 years

Concerns have been expressed about systemic spread of

formocresol from the tooth side and possible toxic reaction (formaldehyde :systemic toxic reaction, cresol : local chemical burn)

Cresol is locally destructive to vital tissue, but its potential for

systemic distribution following pulpotomy treatment is negligible

The major concern has been with the formaldehyde component of

formocresol. ( Although a 1:5 dilution of formocresol is specified

in undergraduate curricula, most (78%) American pediatric

dentists who use formocresol in primary tooth pulpotomy use it at

full strength (19% or 48.5% formaldehyde))

Only 2% of American pediatric dentists use a predictably accurate

dilution of formocresol
Three areas of concern have been reported with regard to

formocresol: mutagenicity, carcinogenicity and immune


Antibody formation leading to immune sensitization to

formaldehyde after formocresol pulpotomy has been

demonstrated in dogs

Mutagenic and carcinogenic effects of formaldehyde exposure

were demonstrated in animal investigations ( nasopharyngeal cancer).

    • Ferric Sulfate 15.5%

Ferric sulphate promotes pulpal hemostasis through a chemical

reaction with blood (it forms a clot over the healthy pulp tissue and this will preserve the vitality of the radicular pulp)
It has been proposed as a pulpotomy agent on the basis that it

forms a protective metal-protein clot over the underlying vital

radicular pulp

Induces favorable histological results in the form of secondary

dentin and bridging

Retention of maximum vital tissue and virtual conservation of the

radicular pulp without induction of reparative dentin

Equivalent clinical, radiographic and succedaneous premolar

outcomes to the formocresol pulpotomy (comparable success rate to formacresol )
Ferric sulfate produces a local but reversible inflammatory

response in oral soft tissues

No concerns about toxic or harmful effects of ferric sulfate have

been published in the dental or medical literature despite regular

clinical use since 1856

Mineral Trioxide Aggregate
Mineral trioxide aggregate has been used successfully in adult

endodontic procedures since the early 1990s

The material has excellent bioactive properties and stimulates

hard tissue formation

It is mixed with sterile water to a sandy consistency, which is

gently packed against the radicular pulp stumps

MTA when used for pulpotomies has a high rate of success

Clinical trials show that MTA performs equal to or better than

formocresol or ferric sulfate and may be the preferred pulpotomy

agent in the future

Cost is a problem especially dealing with primary molars

Portland Cement

Portland cement may serve as an effective and less expensive

MTA substitute in primary molars pulpotomies

Further studies and longer follow-up assessments are needed.

Good luck 

Done by: Fatin Jbarah

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