Pulp Therapy in Pediatric Dentistry Review

Pulp Therapy in Pediatric Dentistry
Dr. Jeff Johnson

Division of Pediatric Dentistry
Department of Oral Health Science
University of Kentucky
--A Review--
Despite the modern advances in prevention of
dental caries and an increased understanding
of the importance of maintaining the natural
dentition, many teeth are still lost
prematurely.
The primary objective of pulp treatment of an

affected tooth is to maintain the integrity
and health of oral tissues.
--A Review--
Additional reasons to preserve the integrity of the
primary dentition are to
1. Reduce the likelihood of mesial drift and the resultant
malocclusion.
2. Aid in mastication.
3. Preserve a pulpally involved primary tooth in the absence
of a succedaneous tooth.
4. Prevent possible speech problems.
5. Maintain esthetics.
6. Prevent aberrant tongue habits
7. Prevent the psychological effects associated with early
tooth loss.
8. Maintain normal eruption time of the succedaneous teeth.
--A Review--
Before attempting pulp therapy in the primary dentition,
the clinician should be familiar with the basic differences
between primary and permanent root canal anatomy.
As a review, the pulp performs five major functions:

Induction
Pulp participates in the induction and development of odontoblasts and
dentin, which, when formed, induce enamel formation.
Formation
Odontoblasts form dentin. Dentin is formed continuously throughout
the life of the tooth. Odontoblasts can also form a unique type of
dentin in response to injury, such as occurs with caries, trauma, and
restorative procedures.
--A Review--
Pulp functions (continued)
Nutrition
Via dentinal tubules, pulp supplies nutrients that are
essential for dentin formation and hydration.
Defense
Odontoblasts form dentin in response to injury,
particularly when the original dentin thickness has been
compromised by caries, wear, trauma, or restorative
procedures. Pulp also has the ability to elicit an
inflammatory and immunologic response in an attempt to
neutralize or eliminate invasion of dentin by caries-
causing microorganisms and their byproducts.
--A Review--
Pulp functions (continued)
Sensation
Through the nervous system, pulp transmits sensations
mediated through enamel or dentin to the higher nerve centers.
The pulp of the primary tooth is histologically similar

to that of a permanent tooth.
Normal pulp has the following histological

components:
Lymph vessels
Blood vessels
Nerve tissue
Undifferentiated mesenchymal cells
Fibroblasts
Defense cells (neutrophils, lymphocytes, an macrophages)
Odontoblasts
Osteoclasts/Odontoclasts
--A Review--
Characteristics of Pulp Tissue
Most similar to connective tissue

Tremendous healing potential
Apical vascularity is important to healing potential
Coronal tissue is more cellular
Apical tissue is more fibrous
Pulp becomes more fibrotic with age
--A Review--
The healing potential of healthy pulp tissue is
a function of:
The vascularity of the pulp.

The absence of cariogenic and inflammatory
bacteria.
The cellular/structural integrity of the
pulp/dentin/enamel complex.
The absence of a chemical and/or thermal insult.
--A Review--
The root canals of anterior primary teeth are relatively simple,
have few irregularities, and are easily treated endodontically.
The root canal systems found in posterior primary teeth,

conversely, contain many ramifications and deltas between
canals making thorough debridement quiet difficult.
Generally, there is only one canal present in each root of the

primary molars when the formation of the roots has been
completed.
The primary tooth root will begin to resorb as soon as the root
length is completed.
The resorption causes the position of the apical foramen to

change continually.
--A Review--
Simultaneously, secondary dentin is deposited within the root
canal system.
The deposition produces variations and alterations in the number

and size of the root canals, as well a many small connecting
branches between the facial and lingual aspects of the canals.
Accessory canals, lateral canals, and apical ramifications of the

pulp may be found in 10 to 20% of primary molars.
Primary teeth have characteristic ribbon-like radicular pulp.
Primary molar roots are widely divergent and curved to allow for
the development of the succedaneous tooth.
--A Review--
The maxillary primary molars may have two to five canals, with
the palatal root usually rounder and longer than the two facial
roots.
In the mesiofacial root, two canals occur in approximately 75%

of the primary maxillary first molars and 85 to 95% of primary
maxillary second molars.
The primary mandibular first and second molars usually have

three canals which generally correspond to the external root
canal anatomy.
Approximately 75% of the mesial roots in primary first molars

contain two canals; whereas in primary second molars, 85% of
the mesial roots contain two canals.
--A Review--
--A Review--
The thickness of enamel and dentin coronal to
the pulp chamber is also thinner in a primary
tooth.
Since the distance from the occlusal surface

and the floor of the pulp chamber is much
shorter than in a permanent tooth, care must
be taken when making an access opening into
the pulp chamber to prevent perforation into
the furcation area.
--Clinical Assessment of Pulp Status--
History of Pain
Three important factors to consider
Duration (how long does it hurt?)
Frequency (how often does it hurt?)
Location (where does it hurt?)
Types of Pain and Pulp Status

Irreversible Nonvital Therapy
Spontaneous/Non-stimulated
Nocturnal
Constant
Types of Pain and Pulp Status (continued)

Reversible Vital Therapy
Thermal
Chemical
Intermittent
Stimulated
Extent of Lesion
Location
Color
Mobility
Differentiate between physiologic root resorption and
pathologic root/bone loss
Soft Tissue Swelling/Lymphadenopathy
Antibiotic treatment for dental infections in

children
Penicillin V 25 50 mg/kg QID/7 days
Clindamycin 16 20 mg/kg QID/7 days
Pulp exposure
Hemorrhagic versus Necrotic
--A Review--
--A Review--
Pulp Testing
Percussion Testing is most reliable in

primary teeth.
Thermal sensitivity Testing is also reliable
in primary teeth.
Electrical Pulp Testing is NOT reliable in
primary teeth (due to the patients
response).
Radiographic Examination
Radiographic evidence of pulpal pathology
includes:
Pathologic bone resorption.
In the presence of infection, bone is destroyed.
The bone destruction is seen in the furcation area of
the tooth.
When the infection is chronic and long-standing, the
resorption can become extensive involving not only the
furcation but the apical areas as well.
The finding of bone resorption is indicative of
widespread pulpal necrosis and nonvitality of the
associated tooth.
Radiographic evidence of pulpal pathology
includes (continued):
Pathologic root resorption. Commonly associated with

pathologic bone resorption is resorption of the root of
the affected tooth itself. Root resorption is indicative
of the presence of the infection for a prolonged period
and generally precludes the employment of any pulp
therapy procedure.
Internal/External resorption. If present, it will

probably be seen in the root canals and again is
evidence of advanced degenerative changes throughout
the pulp. Pulp therapy will generally not be successful
as the resorptive process is not readily retarded.
Radiographic evidence of pulpal pathology includes
(continued):
Calcific changes. Calcified bodies (known as calcific

masses or globules) present in the pulp indicate advanced
pulpal degeneration with inflammation spread throughout
the coronal portion of the pulp.
Widened periodontal membrane/ligament. A widened PDL

is usually indicative of pulpal pathology.
There is a poor correlation between clinical

symptoms and histologic pulp status.
Infected Pulp
Pain Parulis Cellulitis

(No Swelling) (With or Without Pain) (Facial Swelling)
Infection Localized Infection Localized Infection Not Localized
Treat Tooth Only Treat Tooth Only

(Pulpal Therapy or Extraction) (Pulpectomy or Extraction)
Moderate Infection Severe Infection

(Patient is taking fluids well; only slightly febrile) (Patient dehydrated and febrile)
Oral Antibiotic Therapy Hospitalization for IV Antibiotic Therapy and Fluids

+ +
Treat Tooth Treat Tooth
--Vital Pulp Therapy--
The treatment objectives for vital pulp
therapy include:
Eradication of infection.
Maintenance of tooth/teeth in a state of health.
Preservation of space for underlying permanent
tooth/teeth.
Capitalization of reparative ability of the pulp.
Techniques of Vital Pulp Therapy
1. Indirect pulp cap/treatment (IPT) Gross Caries

Removal
2. Direct pulp cap/treatment (DPT)
3. Pulpotomy (formocresol)
4. Pulpotomy (other categories of medicaments)
5. Pulpotomy (non-pharmacotherapeutic)
6. Partial pulpectomy
Indirect Pulp Cap/Treatment (IPT)
Definition: In essence, an IPT is the application of a drug

over a minimal amount of carious dentin with no clinical
exposure of the pulp with the objective of generating
reparative dentin formation beneath the carious lesion.
Indicated when the chance of pulp exposure with complete

caries removal is 75 %.
Place calcium hydroxide (Dycal) or other medicament (i.e.

Vitrabond, Fuji II, etc.) over remaining caries.
The temporary restoration and marginal seal are key to

success.
Can be done in primary and permanent teeth.

Primary Tooth Direct Pulp Cap/Treatment
Contraindicated for carious pulp exposures

Valid for small mechanical or traumatic exposures
Optimal chance for favorable prognosis depends on case
selection
At UKCD, direct pulp caps on primary teeth are not
considered ideal or acceptable treatment
Permanent Tooth Direct Pulp Cap/Treatment
Valid for carious lesions in close proximity to pulp but not

carious exposures
Valid for mechanical or traumatic exposures
Case selection is critical
Pulpotomy (Pharmacotherapeutic)
Objectives
1. Preserve vitality of radicular pulp

2. Amputate infected coronal pulp
3. Treat remaining pulp with medicament
4. Neutralize residual infectious process
5. Avoid dystrophic pulpal change
6. Avoid breakdown of periradicular area
Indications
1. Mechanical or carious exposure

2. Inflammation limited to coronal pulp
3. Absence of spontaneous pain
4. Absence of swelling or alveolar abscess formation
Pulpotomy (continued)
Contraindications
History of unprovoked toothache

Presence of fistula or swelling
Evidence of necrotic/irreversibly damaged pulp
Uncontrolled pulpal hemorrhage
Periapical or bifurcation radiolucency
Pathologic resorption of pulp
Dystrophic calcification
Primary root length less than 2/3
Formocresol Pulpotomy
Success Rate
62 to 97% (depending on the study and follow up
protocol)
Clinical Success Radiographic Success Histological
Success
Formocresol is the standard against which pulpotomy
alternatives are rated.
Actions of Formocresol in Pulpotomy
Technique
Fixation with progressive fibrosis

Acidophilic zone: fixation
Pale staining zone: atrophy
Broad zone of inflammatory cells
Bactericidal
No dentinal bridging
Formocresol Local Toxicity
Ranly, 1984
Histologic failurepersistent chronic inflammation
Immunologic risk
Succedaneous tooth damage
Effect on exfoliation (accelerated?)
Lack of resorbability
Formocresol Tissue Effects
Highly toxic to cells

Depresses fibroblastic respiration and
matrix synthesis
Blocks RNA and protein synthesis
Chronic inflammatory response
May be a systemic concern when doing
multiple treatments (i.e. OR case)
Dilution of Formocresol (Morowa, Garcia-Godoy)
1/5 dilution
1 part formocresol
3 parts glycerin
1 part distilled water
Comparable to full strength in terms of histology
and clinic success
Neither produces ideal histology
Long-term clinical success of 1/5 dilution is
questionable
At UKCD, we use Buckleys Solution (19%
Formaldehyde, 35% Cresol, and 17.5% Glycerin)
Time of Formocresol Application
Direct relation between application time and inflammation

One minute produces less inflammation than 5 minutes
Neither time shows inflammation in apical third
Prevalence of Formocresol Use
The majority of pediatric dentists worldwide (76.8%) utilize

full-strength formocresol or the one-fifth dilution as the
preferred pulpotomy medicament for vital primary teeth
(Fuks, 1991).
Formocresol Pulpotomy Technique at UKCD
(Primary Tooth)
1. Identification/Diagnosis of offending tooth

based upon diagnostic criteria (history,
symptoms, radiographic and clinical evaluation)
Can Vital Pulp Therapy provide adequate and

appropriate care for the patient?
(continued)
2. Obtain Informed Consent
Explain to the parent/legal guardian the

procedure. Answer any questions to his/her
satisfaction. Document in the chart that you
have been granted verbal consent for the
pulpotomy procedure.
(continued)
3. Achieve adequate anesthesia
4. Place Rubber Dam

Rubber Dam Placement/Utilization is a Necessity when
performing pulp therapy!
Formocresol
Pulpotomy Technique
at UKCD (continued)
5. With a slow speed

hand piece, remove
caries
Formocresol
Pulpotomy Technique
at UKCD
(continued)
6. With a high speed hand

piece and a 330 bur,
remove roof of pulp
chamber exposing all
canals
Formocresol
Pulpotomy Technique
at UKCD
(continued)
7. Remove all coronal pulp

with a slow speed hand
piece and a #4 or #6
round bur. Remove all
vital tissue ledges
near canal orifices.
Technique at UKCD
(continued)
8. After all coronal pulp

tissue has been removed,
wet 2-3 cotton pellets
with formocresol and
squeeze between
2 x 2 gauze to remove the
excess. Place cotton
pellets in the pulp
chamber (making sure
that they contact the pulp
tissue in the coronal
portion of the canals) for
5 minutes.
(continued)
9. If hemorrhage has ceased, place a thick mix of

zinc oxide and eugenol paste into the chamber
(use an amalgam carrier and a cotton pellet to
ensure proper condensation/placement).
Technique at UKCD
(continued)
10. Complete the planned

restoration. A tooth
having had vital pulp
therapy will require full
coverage protection (i.e.
Stainless Steel Crown)
for long-term success.

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Pulp Therapy in Pediatric Dentistry Review

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Pulp Therapy in Pediatric Dentistry

Dr. Jeff Johnson

The primary objective of pulp treatment of an

As a review, the pulp performs five major functions:

The pulp of the primary tooth is histologically similar

Normal pulp has the following histological

Most similar to connective tissue

The vascularity of the pulp.

The root canal systems found in posterior primary teeth,

Generally, there is only one canal present in each root of the

The resorption causes the position of the apical foramen to

The deposition produces variations and alterations in the number

Accessory canals, lateral canals, and apical ramifications of the

Primary teeth have characteristic ribbon-like radicular pulp.

In the mesiofacial root, two canals occur in approximately 75%

The primary mandibular first and second molars usually have

Approximately 75% of the mesial roots in primary first molars

Since the distance from the occlusal surface

Types of Pain and Pulp Status

Types of Pain and Pulp Status (continued)

Antibiotic treatment for dental infections in

Percussion Testing is most reliable in

Pathologic root resorption. Commonly associated with

Internal/External resorption. If present, it will

Calcific changes. Calcified bodies (known as calcific

Widened periodontal membrane/ligament. A widened PDL

There is a poor correlation between clinical

Pain Parulis Cellulitis

Infection Localized Infection Localized Infection Not Localized

Treat Tooth Only Treat Tooth Only

Moderate Infection Severe Infection

Oral Antibiotic Therapy Hospitalization for IV Antibiotic Therapy and Fluids

1. Indirect pulp cap/treatment (IPT) Gross Caries

Definition: In essence, an IPT is the application of a drug

Indicated when the chance of pulp exposure with complete

Place calcium hydroxide (Dycal) or other medicament (i.e.

The temporary restoration and marginal seal are key to

Can be done in primary and permanent teeth.

Contraindicated for carious pulp exposures

Permanent Tooth Direct Pulp Cap/Treatment

Valid for carious lesions in close proximity to pulp but not

1. Preserve vitality of radicular pulp

1. Mechanical or carious exposure

History of unprovoked toothache

Fixation with progressive fibrosis

Highly toxic to cells

Direct relation between application time and inflammation

Prevalence of Formocresol Use

The majority of pediatric dentists worldwide (76.8%) utilize

1. Identification/Diagnosis of offending tooth

Can Vital Pulp Therapy provide adequate and

2. Obtain Informed Consent

Explain to the parent/legal guardian the

3. Achieve adequate anesthesia

4. Place Rubber Dam

5. With a slow speed

6. With a high speed hand

7. Remove all coronal pulp

8. After all coronal pulp

9. If hemorrhage has ceased, place a thick mix of

10. Complete the planned

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