Paper 223 Disc

International Journal of Paediatric Dentistry 2000; 10: 248±252

UK National Clinical Guidelines in Paediatric Dentistry*

Introduction
The eighth National Clinical Guideline in Paediatric Dentistry is published here. The process of guideline
production began in 1994, resulting in ®rst publication in 1997. Each guideline has a nominated main author
but the content is not a personal view; it represents rather a consensus of opinion of current best clinical
practice. Each guideline has been circulated to all consultants in Paediatric Dentistry in the UK, to Council of
BSPD, and to people of related specialities recognized to have expertise in the subject. The ®nal version of the
guideline is produced from a combination of this input and thorough review of published literature. The
intention is to encourage improvement in clinical practice and to stimulate research and clinical audit in areas
where scienti®c evidence is inadequate. Evidence underlying recommendations is scored according to the
SIGN classi®cation and guidelines should be read in this context. For those wishing for further detail, the
process of guideline production in the UK is described in International Journal of Paediatric Dentistry 1997; 7:
267±268.

The pulp treatment of the primary dentition

D. R. LLEWELYN
Alder Hey Children's Hospital, Liverpool

Introduction Indications and contra-indications for retaining the

The most common cause of pulpal exposure is
caries, but it may occur during cavity preparation or
as a result of erosion or fracture of the crown.
Pulpal exposures secondary to caries are more
common in primary teeth due to the relatively large
size of the pulp chambers. Following pulpal
exposures, infection may occur and this results in
pulpal in¯ammation and commonly necrosis. This
does not always lead to pain, because the in¯amma-
tion can remain subacute or chronic, but the
situation may become acute at any time.
Primary teeth with pulpal exposures should always
be treated and this takes the form of either pulp
treatment or extraction. If extractions are undertaken
consideration should then be given to space main-
tenance and balancing and compensating extractions.
*Copyright for these guidelines is held by the Faculty of Dental
Surgery, Royal College of Surgeons.
primary dentition
Indications (Grade C)
Where a primary tooth is to be conserved rather
than extracted, pulp treatment is indicated:
. where the patient exhibits signs and symptoms of
pulpitis, either reversible or irreversible;
. where the interproximal marginal ridge has been
lost secondary to caries;
. where there is radiographic evidence of caries
extending more than half way from the Amelo±
dentinal junction to the pulp;
. where there are clinical signs of pulpal necrosis.
Extraction of primary teeth should be avoided in
the following circumstances:
. Medical, e.g. haemophilia or other bleeding
diatheses, diabetes where a general anaesthetic
is to be avoided.

248 # 2000 Faculty of Dental Surgery, Royal College of Surgeons

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The pulp treatment of the primary dentition 249

. Patient compliance±previous unhappy experience Management

of tooth extraction; the patient here may ®nd pulp
treatment preferable and less stressful (Grade C). Preparation
. Primary dentition in which all the molars are
Local anaesthesia should be attained and where
present or where space maintenance has pre-
possible the tooth isolated with rubber dam.
vented loss of arch dimension.
. Dentitions in which there is shortage of space±
tooth loss here would lead to further crowding of Indirect pulp capping
the permanent successors.
The aim here is to maintain the vitality of the
. Retention of primary teeth when there is no
pulp by placing a dressing indirectly on a thin layer
permanent successor.
of dentine [1].
. Maintenance of masticatory function.
The most commonly used medicament for indir-
. Aesthetics.
ect pulp capping is calcium hydroxide as it
stimulates secondary dentine formation. The prog-
Contra-indications nosis for indirect pulp capping is good, whereas
direct pulp capping of carious exposures in primary
Patients for whom pulp treatments are not
teeth carries a poor prognosis, with internal resorp-
advised or contraindicated:
tion being a frequent sequel (Grade B).
. A patient who has previously failed to comply
Other medicaments have been suggested instead
with dental treatment (Grade C).
of calcium hydroxide, e.g. antibiotic pastes and anti-
. A patient whose family background precludes
in¯ammatory drugs [2]. Some success has been
pulp treatment, i.e. an unfavourable attitude
reported, but the eventual development of pulp
towards dental treatment.
necrosis and abscess formation tend to occur, often
. Medical problems ± patients whose general health
without symptoms (Grade C).
is at risk from transient bacteraemias, e.g.
Recent research has suggested that adhesive
children with congenital heart disease and those
dental materials and bonding agents may be suitable
who are immunocompromised either due to
for indirect pulp capping in permanent teeth. Their
primary disease (e.g. hypogammaglobulinaemia)
ecacy in primary teeth remains untested (Grade B).
or medical treatment (oncology patients and
transplant recipients).
. A poorly cared for dentition in which multiple Direct pulp capping (Grade B)1
extractions are necessary ± usually considered to
Direct pulp capping aims to maintain pulpal
be more than two or three teeth in need of pulp
vitality by direct placement of a material, usually
treatments.
calcium hydroxide, in contact with the coronal pulp.
. Mixed dentitions in which there is mild to
For cariously exposed primary molars the vital
moderate shortage of space, particularly in the
pulpotomy technique is preferred, because the
incisors. Here balanced loss of the ®rst primary
success of direct pulp capping in these teeth has
molars may be justi®ed. This will probably result
been shown to be inferior.
in the extractions of premolars at a later stage.
Primary second molars should be retained if at all
possible to prevent mesial drift of the ®rst Pulpotomy (Grade B)
permanent molars on eruption.
A pulpotomy is the procedure of removing the
. A grossly broken down primary molar, where
coronal portion of the pulp tissue, with the aim of
there is insucient tooth tissue remaining for a
removing all infected or in¯amed tissue, but leaving
viable coronal restoration.
. A tooth with caries penetrating the ¯oor of the
pulp chamber. 1
Statistically direct pulp capping has been found to be less
. A tooth close to exfoliation (i.e. with less than successful in primary teeth than indirect pulp therapy or coronal
amputation (pulpotomy). The highest success rates have been
two-thirds of root length remaining). obtained in teeth with non carious exposures and no signs of pre-
. A tooth with advanced pathological root existing pulpal in¯ammation. Success in cariously exposed
resorption. primary teeth is poor.

# 2000 Faculty of Dental Surgery, Royal College of Surgeons, International Journal of Paediatric Dentistry 10: 248±252

250 D. R. Llewelyn
a vital radicular pulp. It is indicated where there is a
carious pulp exposure, with or without signs or
symptoms of pulpitis, but where the radicular pulp
remains vital and unin¯amed.
A pulpotomy is performed on vital teeth with
carious pulp exposures deemed unsuitable for pulp
capping. Primary molars with loss of more than
two-thirds of the marginal ridge usually require a
pulpotomy, because the coronal pulp in these teeth
is often irreversibly in¯amed [3].
There are three pulpotomy techniques:
1 Vital Formocresol Pulpotomy Technique ± also
known as the `5-minute formocresol pulpotomy'
and the `one-stage' pulpotomy ± here the coronal
pulp is removed after adequate analgesia and the
vital radicular pulp stumps are treated with
formocresol [4,5].
2 Devitalization Pulpotomy ± this is a two-stage
technique and relies upon paraformaldehyde to ®x
the coronal and radicular pulp tissue.
3 Non-Vital Pulpotomy ± this technique is carried
out when the in¯ammatory process a€ecting the
coronal pulp extends to the radicular pulp leading
to an irreversible change in the pulp tissue.
Vital Formocresol Pulpotomy Technique (one-stage,
5-minute formocresol pulpotomy)2. It is essential to
obtain analgesia prior to removal of caries and the
coronal pulp. This usually means an inferior dental
nerve block for lower teeth, an in®ltration is
adequate for upper molars. All the caries is removed
and the cavity is extended so that the entire roof of
2
Constituents of Buckley's Formocresol
Tricresol 35%
Formaldehyde 19%
Glycerol 15%
Water 31%
A dilution of this formulation 1 in 5 has been shown to be equally
as e€ective and less toxic. This 1 : 5 dilution is now advocated by
most authorities. Other medicaments have been evaluated as an
alternative for the vital pulpotomy technique, but none have been
shown to perform as well as formocresol.
Glutaraldehyde has been suggested by S'Gravenmade as an
alternative to formocresol [6]. However, recent studies have
demonstrated a similar or lower clinical success rate than
formocresol and concerns about hypersensitivity reactions and
the handling of glutaraldehyde mean it has few advocates as a
replacement for formocresol. Calcium hydroxide has also been
used as an alternative to formocresol, but its success has been
poor compared with formocresol with marked internal resorption
reported. Other reported techniques include electrosurgery, ferric
sulphate and enriched collagen solution. The ecacy of these
approaches awaits full evaluation [7].
# 2000 Faculty of Dental Surgery, Royal College of Surgeons, International Journal of Paediatric Dentistry 10: 248±252
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the coronal pulp chamber is breached. A large
excavator or a sterile large rosehead bur is used to
remove the coronal pulp tissue and the haemor-
rhage is controlled by pressure from sterile cotton
wool pledgets. A small pledget of cotton wool
dipped in a 1 : 5 dilution of Buckley's formocresol
and squeezed to remove excess liquid is placed over
the radicular pulp stumps for 4±5 minutes. This
pledget is then removed and if the haemorrhage has
stopped, the pulp chamber is ®lled with a hard
setting glass ionomer or zinc oxide eugenol cement
and the tooth restored, preferably with a preformed
metal crown, because the crown of a tooth after
such a pulpotomy is weak and may fracture.
Follow-up of the pulpotomized tooth should be
regular and annual radiographs advisable to check
on the furcation area. Rarefaction of bone in this
area signi®es failure and a pulpectomy or extraction
may be needed.
Devitalization Pulpotomy (Grade B)3. This is a
two-stage procedure and relies upon the use of
paraformaldehyde to ®x (mummify) the coronal and
radicular pulp tissue.
This technique carries a lower success rate than
the formocresol vital pulpotomy, but may be useful
where adequate local analgesia for pulpal extirpa-
tion cannot be obtained. The paraformaldehyde
paste is placed over the pulpal exposure on a small
pledget of cotton wool, the larger the exposure then
the more successful the outcome. Formaldehyde
vapour liberated from the paraformaldehyde
permeates through the coronal and radicular pulp,
®xing the tissues. The paraformaldehyde paste is
sealed into the cavity with a thin mix of zinc oxide
eugenol and left for 1±2 weeks. At the second visit,
the dressing is removed, there is no need to
administer a local anaesthetic as the pulp contents
should be nonvital, the pulp remnants should be
excavated leaving the radicular pulp stumps. These
are then covered with hard setting zinc oxide cement
or, alternatively, an antiseptic dressing (equal parts
of eugenol and formocresol with zinc oxide) and
3
Constituents of paraformaldehyde paste (mummifying paste)
Paraformaldehyde 1G
Lignocaine 0.06G
Carmine 10.0 mg
Propylene glycol 0.5 mL
Carbowax 1500 1.3G

the cavity ®lled with a hard setting cement base
and restored.
Non-Vital Pulpotomy (Grade B)4. This technique
has been advocated when the in¯ammatory process
a€ecting the coronal pulp extends to the radicular
pulp leading to an irreversible change in the pulp
tissue. Another application for this technique is
when the pulp is completely nonvital, where there
may be an abscess present with or without acute
cellulitis. However, only limited data are available
relating to this technique and this indicates a low
success rate (approximately 50%).
Technique. lst visit ± The necrotic coronal pulp is
®rst removed, as recommended in the vital pulpot-
omy technique, the necrotic debris in the pulp
chamber is then cleared. If there is sucient access
to the radicular pulp canals then as much as possible
of the necrotic tissue is removed with a small
excavator. A small pledget of cotton wool dipped in
beechwood creosote solution is then placed over the
pulp stumps after removing excess solution by
dabbing on a sterile cotton roll. The beechwood
creosote is then sealed into the cavity with a
temporary zinc oxide eugenol cement.
2nd visit ± Usually 1±2 weeks later the dressing is
removed, provided the signs and symptoms of
infection have cleared, i.e. any sinus present is
resolving, there has been no pain and no mobility of
the tooth. The cavity is then restored in the same
manner as used in the vital pulpotomy technique.
However, if it appears that there is no resolution of
the symptoms then the beechwood creosote should
be replaced for a further 1±2 weeks.
Pulpectomy (Grade B)
Pulpectomy is indicated where the radicular pulp
is irreversibly in¯amed or has lost vitality. This
technique is often considered impracticable because
of the diculty in obtaining adequate access to
the root canals and because of the complexity of
root canals in primary molars. The canals are
ribbon shaped and may have several inter commu-
4 4 Redig DF. A comparison and evaluation of two formocresol
Constituents of beechwood creosote
2 Methoxy, 4 Methyl phenol (Cresol) 13%
0±Methoxy phenol (Guaicol) 47%
M±Methoxy phenol 7%
P±Methoxy phenol 26%
Unknown 7%
# 2000 Faculty of Dental Surgery, Royal College of Surgeons, International Journal of Paediatric Dentistry 10: 248±252
Paper 223 Disc
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The pulp treatment of the primary dentition 251
nicating canals [8]. However, more recent retro-
spective clinical studies have demonstrated a
relatively high success rate [9±12].
Technique. The coronal pulp is removed as for the
vital pulpotomy technique, the pulp may be necrotic
or showing irreversible in¯ammation as evidenced
by persistent bleeding even after a 4-minute
application of formocresol. Depending on the state
of the pulp, i.e. irreversibly in¯amed or necrotic,
then a one- or two-stage technique is described.
One-Stage Technique (Grade C) ± The root
canals are identi®ed, they usually have the same
number of canals as permanent molars and they are
then cleared out with ®les to within 1 or 2 mm of the
apex. The canals are ®led lightly, because the roots
are fragile: reamers are not used as this may result in
damage to the roots. Filings should be to no more
than size 30. The root canals are then dried with
paper points. Formocresol may be placed over the
root canals for 4 minutes. Pure zinc oxide and
eugenol is then mixed into a slurry and carried into
the root canals with a spiral root canal ®ller. The
rest of the pulp chamber is then restored as for the
previous pulpotomy technique and appropriate
follow-up appointments are made.
Two-Stage Technique (Grade B) ± Visit 1: The
necrotic pulp contents are removed, any ®stula can
be punctured to enhance drainage if necessary. The
root canals are ®led and irrigated and the pulp
dressed with formocresol on a pledget of cotton
wool, the cavity is sealed with zinc oxide and
eugenol for a week. Antibiotics are given if there is
associated cellulitis.
Visit 2: The symptoms should have resolved and
the tooth treated as for the one-stage technique.
References
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Dental Journal 1972; 133: 95±101.
2 Hargreaves JA. Maintenance of exposed deciduous teeth with
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International Symposium of the International Association of
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3 Hobson P. Pulp treatment of deciduous teeth. Part 2. Clinical
investigation. British Dental Journal 1970; 128: 275±283.
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5 Morawa AP, Stra€on LH, Han SS, Corpron RE. Clinical
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6 S'Gravenmade EJ. Some biochemical considerations on

252 D. R. Llewelyn
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# 2000 Faculty of Dental Surgery, Royal College of Surgeons, International Journal of Paediatric Dentistry 10: 248±252
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