Pulp therapy in

primary teeth
• Dental caries, trauma and the iatrogenic effects of conservative
dental treatment, all provoke a biological response in the pulpo-
dentinal complex.
• extension of dental disease
• to restore damaged teeth to healthy function.
Role of primary teeth

• Role in the development of the occlusion.

• loss of space, increasing the chances of developing a malocclusion and
orthodontic treatment need
• reduced masticatory function (especially posterior teeth)
• psychological disturbance (especially anterior teeth)
• extraction of teeth has been identified as a cause of future dental anxiety
 Diagnosis

• Clinical history
• • Reported history of pain and symptoms from the tooth.
• CLINICAL ASSESSMENT
• • The presence of an abscess, excessive mobility, swelling, or tenderness to percussion—this indicates that the
tooth is
• INFECTED AND NON-VITAL.
• • Is the tooth restorable?
• • Extent of marginal ridge breakdown.
• • Site of caries—occlusal or proximal?
• RADIOGRAPH ASSESSMENT
• • Root length.
• • Perifurcational radiolucency.
• • Internal resorption seen in root canal
Diagnosis of pulpal status

• Effective pulpal therapy requires the correct assessment and

interpretation of clinical signs and symptoms, leading to an accurate
diagnosis of the pulpal condition.
• Ineffective or inappropriate pulp therapy is associated with both
acute and chronic clinical signs and symptoms.
Acute signs and symptoms include:
• • Pain.
• • Mobility.
• • Periapical or intra-radicular abscess.
• • Facial cellulitis, including spread of infection into the tissue planes around the airway.
Chronic signs and symptoms include:
• • Persistent infection.
• • Discharging sinus.
• • Inflammatory follicular cyst (see Chapter 10).
• • Failure of exfoliation of primary teeth.
• • Apical fenestration.
• • Ectopic permanent teeth
Pulp sensibility tests

• Standard techniques of pulp sensibility testing are of limited value

in children.
Pain

• Symptoms of severe, prolonged, spontaneous or nocturnal pain

suggest irreversible pulpitis or a dental abscess
Other clinical signs

Careful clinical examination of teeth can reveal useful diagnostic information.

• Coronal discoloration is suggestive of pulp necrosis.
• Clinical mobility is associated with loss of bone from infection or imminent
exfoliation.
• Marginal ridge fracture in a primary tooth is suggestive of carious pulpal
involvement in contact point caries.
• Fracture of the occlusal triangular ridges or carious undermining of the cusps in pit
and fissure caries also suggests carious involvement.
Radiographs

Radiographs will show

• The extent of the carious lesion
• The position and proximity of pulp horns
• The presence and position of the permanent successor.
• The status of the roots and of their surrounding bone.
Swelling

• Alveolar swelling, particularly involving the vestibular reflection,

• Facial swelling.
• Coronal discoloration.
• The presence of a sinus.
are indicators of pulp necrosis and abscess formation.
Mobility

• Inappropriate tooth mobility, tenderness to palpation or a sensation

of occlusal interference also suggests abscess formation.
FACTORS IN TREATMENT PLANNING

• Medical history
• Behavioral factors
• Dental factors
Treatment options for the inflamed pulp

• There are a number of different treatment options for carious

primary teeth with an inflamed pulp.
• For these to be successful, all clinical and radiographic findings
must be collected and evaluated to ensure that the most appropriate
treatment option is chosen.
(A) Loss of marginal ridge of first primary molar suggests carious pulpal
involvement. (B) Undermined triangular ridge or cusp suggests carious pulpal involvement.
Treatment options for primary teeth
Treatment options for the inflamed pulp

• Hall technique
• In direct Pulp capping
• Direct pulp capping
• Pulpotomy
• Pulpectomy
Hall technique: a biological approach with
no caries removal

• The Hall crown technique is essentially the ultimate minimally

invasive restoration as
• It involves the placement of stainless steel crowns, directly over
carious lesions, in primary molars, with little, or no, tooth
preparation or caries removal.
Indications

• Primary molar teeth with moderate decay, but no clinical signs or

symptoms of pulpal pathology.
• Dentitions of children with limited cooperation, who are unable to
accept conventional restorative treatment with local anesthesia.
• Healthy children.
Technique
This technique is used without local anesthetic:
1. Pre-procedure radiograph and examination to exclude pulpal pathology.
2. Orthodontic separators may be placed at a prior appointment, to ease placement
of the crown.
3. Child should be sat upright or semi-reclined, but not supine and gauze may be
used to protect the airway.
4. The tooth can be cleaned with a toothbrush and if desired gross caries may be
removed with a hand excavator.
5. A stainless steel crown is selected, which will fit over the tooth without any
preparation.
6. A GIC cement is placed in the crown which is bitten into place by the child.
7. Excess cement may be washed or wiped away, before it has set.
Indirect pulp capping (IPC)

• A clinical dilemma is presented by a deep lesion in a vital

symptom-free tooth where complete removal of softened dentine on
the pulpal floor is likely to result in frank exposure.
Technique:

• All caries is first cleared from the cavity margins with a steel round bur running at slow
speed.
• Gentle excavation then follows on the pulpal floor, removing as much of the softened
dentine as possible without exposing the pulp.
• A thin layer of setting calcium hydroxide cement
• The indirect pulp cap was covered with zinc oxide–eugenol cement or glass ionomer.
• After observation for several weeks, the cavity was re-entered to remove all remaining
softened dentine and restore it.
Direct pulp capping (DPC)

• The success rates for DPC are poorer than for other pulpal
treatments and therefore are not recommended for use in primary
dentition.
PULPOTOMY

• Pulpotomy is the most widely used endodontic technique in the

primary dentition.
• The aim of pulpotomy in the primary tooth is to amputate the
inflamed coronal pulp and preserve the vitality of the radicular pulp,
thereby facilitating the normal exfoliation of the primary tooth.
Indications for pulpotomy in primary teeth

• Carious pulp exposure.

• Tooth asymptomatic or mild transient pain.
• Preoperative radiograph confirms the absence of radicular
pathology.
• Restorable tooth.
Technique

1. Pain control and rubber-dam isolation.

2. Complete removal of caries from peripheral to pulpal.
3. Removal of roof of pulp chamber.
4. Amputation of coronal pulp.
5. Arrest of bleeding at amputation site
6. Application of therapeutic agent
7. Place base directly on to pulp amputation site.
8. Place core.
9. Restore tooth with a preformed metal crown (molars) or a composite resin strip crown for anterior teeth.
10. Regular radiographic assessment.
Clinical view of a pulpotomy
procedure. (A) Bitewing radiographs show
deep carious lesion in tooth 74. (B) Access
into pulp chamber and amputation of
coronal pulp. (C) Ferric sulphate applied to
amputated pulp. (D) Appearance of treated
pulp following rinsing of ferric sulphate.
(E) IRM base completely sealing pulpotomy
site. (F) Build-up of crown with glass ionomer
cement prior to final restoration. (G) Tooth
restored with stainless steel crown.
Therapeutic agents used for pulpotomy in
primary teeth

• Form cresol,
• Ferric sulphate.
• Aldehydes.
• Calcium hydroxide
• MTA
• Electrocautery
.
Follow-up

• Clinically, the following criteria indicate success:

• absence of symptoms
• absence of any abscess or draining sinus
• no excessive mobility or tenderness
• retention of the tooth until it would exfoliate naturally.
Radiographically, the following should be observed.
1. No evidence of bone loss in the furcation region. Figure 9.19(e) demonstrates good bone
condition in the bifurcation region 6 months after the pulpotomy was performed.
2. No evidence of internal resorption.
Pulpectomy in primary teeth

• Pulpectomy is the complete removal of all pulpal tissue from the

tooth.
• Pulpectomy can only be considered for primary teeth that have
intact roots.
Indications

• Pulp necrosis in any primary tooth, or carious exposure of vital

primary incisor.
• Restorable tooth.
• Preoperative radiograph confirms intact non-resorbed root.
• Retention of tooth is required.
Technique

1. Pain control and rubber-dam isolation.

2. Complete removal of caries.
3. Chemo-mechanical cleaning and preparation of the root canal, taking care to force
neither instruments nor debris beyond the anatomical apex. Copious irrigation with
sodium hypochlorite.
4. Obturation with a resorbable paste (see above).
5. Restoration to ensure adequate coronal seal.
6. Regular radiographic assessment.
 (a) Periapical radiograph showing files
placed in the root
canals of left lower second primary
molar. (b) Root canals have
been filled with pure zinc oxide–
eugenol
Root canal filling in an
upper primary central
incisor