Primary Tooth Pulp

Therapy

Dr. Berry DDS MPH MSD

Biologic Consideration of
Regional Necrosis
 Pulpal changes are observed at the initiation of a
carious lesion in enamel
 The pulpal response increases in severity (hyperemia)
with the advancing lesion
 Elimination of minor lesions may result reversal of
pulpal inflammation
 If not reversed, pulpal inflammation will become
irreversible with subsequent necrosis
 Irreversible changes initially occur close to the
infecting agents/irritants leading to regional necrosis
prior to complete necrosis of the entire pulp
 Primary Diagnostic Parameters

 History
 Clinical Examination

 Radiographic Examination
 HISTORY
 Chief Complaint, Past Medical Hx
 Healthy
 Immuno-compromised

 Young patient’s lack verbal ability to

respond
 Guardian’s response
 Missed school days and lethargy
 Pain
PAIN HISTORY
 Acute
Stimulated/Solicited
 sharp, short lasting following stimulation
 if spontaneous is usually an indicator of
pulpal degeneration
 Chronic
Unstimulated/Unsolicited
 pain unsolicited by stimulation
 Good indication of pulpal degeneration
 Absence of Pain does not mean healthy
CLINICAL EXAMINATION

 Soft Tissue
 redness, parulis and/or swelling
around a tooth
CLINICAL EXAMINATION

 Mobility
 excessive mobility can indicate
pathology in surrounding tissue
 Physiologic resorption

 Percussion
 sensitivity to percussion may indicate
pathology
 child’s response variable
 RADIOGRAPHIC
INTERPRETATION
 Depth and location of caries

•Presence of abnormal calcific masses

•Presence and degree of bone and root

resorption
 PULP THERAPY

 Direct Pulp Cap

 Indirect Pulp Cap

 Pulpotomy

 Pulpectomy
 DIRECT PULP CAP
Placing a base and liner over a small mechanical pulp exposure

 Diagnosis indicated a healthy pulp

 Absence of pain
 Pulp is not exposed to caries
 Small mechanical exposure - 1mm.
 Pulpal bleeding is normal and easily controlled
 Generally not indicated for primary teeth
 If you are into the pulp then complete a pulpotomy
 INDIRECT PULP CAP
Placing a base and liner over caries that would otherwise result in
a pulp exposure

 No indications of pulpal exposure

 No unstimulated or long term pain

 No signs or symptoms of pulpal

degeneration
 INDIRECT PULP CAP

 Most dentists do not re-enter

 One-step technique
 Partial caries removal preferable to complete caries
removal
 Reduces risk of carious exposure
 Purposely avoid pulp exposure
 Unbroken layer of firm, leathery dentin covering the
pulp
 INDIRECT PULP CAP

 Most appropriate treatment for symptom-

free primary teeth with deep caries
 Key to success if a leakage-free restoration
 Arrests the progression of the underlying
caries
 Flora type changes – slow lesion progress
found on root caries
 Research on the flora remaining “inactive”
beneath restoration incomplete
 INDIRECT PULP CAP
 Recent literature/research:
 Formocresol and ferric sulfate pulpotomy have significantly lower
long-term success for treatment of deep caries compared with IPT
 IPT has shown higher success rate for teeth with reversible pulpitis
compared with formocresol pulpotomy
 IPT has shown higher long-term success rates than pulpotomy
(excluding MTA pulpotomy)

Coll, JA. Indirect pulp capping and primary teeth: is the primary tooth
pulpotomy out of date? Pediatr Dent 2008; 30: 230-236.
 PULPOTOMY

 Indication and Contraindications

 Technique
 Formocresol
 Ferric Sulfate – Fe2(SO4)
 MTA (Mineral Trioxide Aggregate)
 Other
 Success
 Failure
 PULPOTOMY
 The amputation of the
coronal portion of the pulp
 The remaining pulp tissue
in the roots is vital
(radicular pulp tissue)
 A number of medicaments
used to cover the
remaining pulp stumps
 INDICATIONS FOR
PULPOTOMY
 Radiographic evidence of pulpal exposure
 May have history of solicited pain
 No history of spontaneous/persistent pain
 Carious pulp exposure
 Bleeding controlled in 3-5 minutes
 Blood appears red and normal (not
necrotic)
 Pulp tissue in canals appears normal
 2/3 root length remaining
 INDICATIONS
FOR PULPOTOMY

 Radiographic evidence of pulpal exposure

 Carious clinical pulp exposure

 CONTRAINDICATIONS
FOR PULPOTOMY
 An unrestorable tooth
 Bi- or trifurcation involvement or the presence of
an abscess
 Less than 2/3 of root remaining
 Permanent successor close to eruption
 PULPOTOMY TECHNIQUE
 Remove caries and determine site of pulp
exposure
 Remove roof of pulp chamber
 Remove coronal pulp tissue
 Control bleeding
 Appropriately use pulpal medicament
(Formocresol, Ferric Sulfate, MTA)
 Fill pulp chamber with cement/restore
 PULPOTOMY TECHNIQUE
 Remove caries and determine site of pulp
exposure
 PULPOTOMY TECHNIQUE
 Remove roof of pulp chamber

 Remove coronal pulp tissue

DIAGNOSIS DURING
THE PROCEDURE
 Nature of the exposure
 Bleeding

 Appearance of the pulp tissue

 Bleeding controlled in 3-5 minutes

 Blood appears red and normal

 Pulp tissue in canals appears normal

 FORMOCRESOL
PULPOTOMY TECHNIQUE
 Control bleeding
 Apply formocresol solution for 5 minutes
Moisten cotton pellet
and blot with sterile
guaze to remove
excess.

Leave pellet in place

for 5 minutes
 FORMOCRESOL
PULPOTOMY TECHNIQUE
 Remove formocresol pellet
 Fill pulp chamber with cement/IRM and restore (SSC)

Strands of tissue
between root
stumps
 FORMOCRESOL
 Bactericidal effect
 Devitalizing effect
 Fixation
 Inhibits autolytic changes and bacterial growth
 Preserves cellular detail
 No dentinal bridging, but calcific changes present
 Composition:
 Formaldehyde (19%), cresol, glycerin, water
 1/5 concentration of Buckley’s
FORMOCRESOL

 Safety concern?
 Formaldehyde is in the air, water, and
food (average 7.8 mg/day)
 Formaldehyde dosage in 1 pulpotomy
procedure with a cotton pellet
squeezed dry = 0.02-0.1 mg
 Low exposure
 FERRIC SULFATE TECHNIQUE
 Control bleeding prior to application of FS
 Place ferric sulfate using syringe with cotton tip
or apply with cotton pellet for 15 seconds
 FERRIC SULFATE TECHNIQUE

 Rinse with water and dry gently with cotton pellet

 Cover pulp stumps with zinc-oxide-eugenol (IRM) or
Glass Ionomer Cement/restore
 MECHANISM OF FERRIC
SULFATE ACTION
 Ferric ion-protein complex formed on
contact with blood.
 Complex membrane of complex
mechanically seals pulp vessels.
 Does not penetrate remaining pulp tissue

 Generally used as a 15.5 % solution

 MTA PULPOTOMY TECHNIQUE

 Control bleeding
 Powder composed of tricalcium silicate, bismuth oxide,
dicalcium silicate, tricalcium aluminate, tetracalcium
aluminoferrite, and calcium sulfate dihydrate
 Place MTA over dry pulp stumps
 Fill pulp chamber with cement/IRM and restore
 Less known, expensive
 COMPARISON OF DIFFERENT
PULP MEDICAMENTS

 All of the studies comparing MTA with formocresol

showed that MTA presented better results, though
some were not statistically significant different.
 Ferric sulfate and dilute formocresol produced similar
results when comparing degree of pulpal response,
dentin bridging and abscess formation.
 In study remaining pulp tissue after pulp amputation
considered to be vital.

Fuks AB. Vital pulp therapy with new materials for primary teeth: New
directions and treatment perspectives. Pediatr Dent 2008; 30: 211-218
 OTHER PULPOTOMY
TECHNIQUES
 Electosurgery
 CO2 Laser
 Gluteraldehyde
 Calcium Hydroxide – not used in primary teeth
as it causes internal resorption
 SUCCESSFUL PULPOTOMY
 Elimination of infection within the tooth
 Tooth is preserved in healthy, non-pathologic
condition
 Arch space is maintained
 Normal resorption of primary tooth and eruption
of permanent successor

Resorption and eruption on pace with opposite side

 FORMOCRESOL
PULPOTOMY SUCCESS
100 Clinical
Radiographic
90 98 98 98
80 95
90 95
70
60
50
65
60
40
30
20
10
0
Morand Magnusson Rolling Fuks
 FAILED PULPOTOMY
 Usually due to extended pathology
 Non-vital root canal tissue
 Periapical / radicular pathology (x-ray should
show)
 May not always be able to detect at time of
procedure
 “When in doubt – take the pulp out”
PULPECTOMY

 Indications and Contraindications

 Technique
 Posterior
 Anterior

 Success
 Failure
 PULPECTOMY
Removal of the
tissue from
the coronal
pulp chamber
and the root
canals
 INDICATIONS FOR
PULPECTOMY
 Inflammation extending
beyond coronal pulp
 Primary teeth with necrotic
pulps
 Roots and surrounding bone
free of pathology
 (success rate falls with
furcation involvement)
 At least 1/2 of root length
remaining
 Second primary molar
retention for the erupting
first permanent molars
 No permanent successor
 PULPECTOMY TECHNIQUE
 Remove caries and determine site of pulp
exposure
 Remove roof of pulp chamber
 Remove coronal pulp tissue and identify root
canals
 Clean out canals and remove pulp tissue
 Dry canals with paper points
 Fill root/coronal chamber with ZnOE/restore
 PULPECTOMY TECHNIQUE
 Clean out canals and remove pulp tissue
 Dry canals with paper points
 Fill root/coronal chamber with
ZnOE/Vitapex and restore (SSC)
 Fill pulp chamber with thickened mix of
paste
 Restore tooth with stainless steel crown
 ZOE versus Vitapex
 ZOE= Zinc Oxide Eugenol
 Vitapex= iodoform and calcium hydroxide
 More short fills with ZOE and long fills with Vitapex
 ZOE – potential to alter path of eruption of permanent teeth
 Trairatvorakul et al found that Vitapex appears to resolve
furcation pathology at a faster rate than ZOE at 6 months,
while at 12 months both yielded similar results

Trairatvorakul,C. Salinee C. Success of pulpectomy with zinc oxide eugeol vs

calcium hydroxide/iodoform paste in primary molars: a clinical study. Pediatr Dent.
2008; 30: 303-308.
 PULPECTOMY
ANTERIOR TEETH

 Large root canal chamber

makes it difficult to seal
canal
 Higher success rate with
pulpectomy
 Procedure same as for
posterior teeth
 May restore with strip crown
or esthetic crown
PULPECTOMY
ANTERIOR TEETH
 SUCCESSFUL PULPECTOMY

 Elimination of infection
within the tooth and
surrounding tissues
 Tooth is preserved in
healthy, non-pathologic
condition
 Arch space is
maintained
 SUCCESS OF
PULPECTOMIES 1 year follow-up -
formocresol pulpectomy
on posterior teeth

% 82

81.5
82 82
S
U 81
C 80.5
C
E 80
S 79.5
80
S
79
Gould Coll Barr
1975 1985 1991
 PULPECTOMY FAILURES

 Not necessary
to fill canal to
the apex.
 Do not force
filling material
past the apex
 Possibility of
damaging
underlying tooth
 PULPECTOMY
ANTERIOR TEETH
 Coll et al found potential to alter path
of eruption of permanent successor
 20% incidence of anterior crossbite or
palatal eruption following incisor
pulpectomies

Coll JA, Sadrian R. Predicting pulpectomy success and its relationship to exfoliation and
succedaneous dentition. Pediatr Dent 1996; 18: 57-63.
 PULPECTOMY FAILURES

There is no
evidence of
radicular
pathology

Tooth is now mobile

and extruded – there is
loss of root structure
with filling material
visible outside of
mesial canal
What is being taught in
Dental Schools
 More schools teaching IPT
 Glass ionomer
 Most don’t reenter
 Decrease in formocresol usage
 Increase in ferric sulfate usage
 ZOE is the preferred base for pulpotomy
 Pulpectomy ZOE filler decreased and
iodoform/calcium hydroxide filler increased
Dunston B, Coll J. A Survey of Primary Tooth Pulp Therapy as
Taught in US Dental Schools and Practiced by Diplomates of the
Aerican Board of Pediatric Dentistry. Pediatric Dentistry 2008;
30:1.
References
 Rickets DNJ, Kidd EAM, Innes N, Clarkson J. Complete or ultraconservative
removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev
2006. CD003808.
 Fuks AB. Vital pulp therapy with new materials for primary teeth: New
directions and treatment perspectives. Pediatr Dent 2008; 30: 211-218.
 Milnes, AR. Is formocrresol Obsolete? A fresh look at the evidence
concerning safey issues. Pediatr Dent 2008; 20: 237-246.
 Federal-Provincial-Territorial Committee on Drinking Water. Formaldehyde:
guidelines for Canadian drinking water quality- supporting documents.
Available at: www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/doc_sup-
appui/index_e.html. Accessed October 21, 2010.
 Seale, SN. Vital pulp therapy for the primary dentition. General Dentistry;
 Glickman GN. AAPD and AAE Symposium Overview: Emerging Science in
Pulp Therapy- New Insights into Dilemmas and Controversies. Pediatr Dent
2008; 30: 190-191.
 Bjorndal L. The caries process and its effects on the pulp: the science is
changing and so is our understanding. Pediatr Dent 2008; 30: 192-205
References
 Trope, M. Regenerative potential of dental pulp. Pediatr Dent 208; 30: 206-
210.
 Coll, JA. Indirect pulp capping and primary teeth: is the primary tooth
pulpotomy out of date? Pediatr Dent 2008; 30: 230-236.
 Waterhouse, PJ. “New Age” pulp therapy: personal thoughts on a hot
debate. Pediatr Dent 2008; 30: 247-252
 Dunston B, Coll J. A Survey of Primary Tooth Pulp Therapy as Taught in US
Dental Schools and Practiced by Diplomates of the Aerican Board of
Pediatric Dentistry. Pediatric Dentistry 2008; 30: 42-48.
 Armstrong, SL. Berg, JH. Ferric-sulfate pulpotomy in primary molars-
indications and technique. Essence 2004; 2: 7-10.
 Trairatvorakul, C. Salinee C. Success of pulpectomy with zinc oxide eugeol
vs calcium hydroxide/iodoform paste in primary molars: a clinical study.
Pediatr Dent. 2008; 30: 303-308.
 Bawazir. OA, Salama, FS. Apical microleakage of primary teeth root canal
filling materials. J of Dent for Children. 2007; 74: 46-56.
 Barr ES, Flatiz CM, Hicks MJ. A retrospective radiographic evaluation of
primary molar pulpectomies. Pediatr Dent. 1991; 13: 4-9.
 Coll JA, Sadrian R. Predicting pulpectomy success and its relationship to
exfoliation and succedaneous dentition. Pediatr Dent 1996; 18: 57-63.