Pulp Therapy

• Pulp therapy aims to maintain the integrity and health of teeth and their supporting tissues.
• In young permanent teeth, pulp therapy aims to continue root growth and development.

Diagnosis

• Pulpal diagnosis is key to determine which pulp therapy to perform.
• Four possible pulpal diagnoses exist.
• Normal pulp is symptom-free with a normal response to testing.
• Reversible pulpitis means the pulp is capable of healing.
• Irreversible pulpitis is when the vital pulp is inflamed and incapable of healing, symptomatic or asymptomatic.
• Necrotic pulp is non-vital pulp.
• Diagnosis is based on patient history, clinical exams and tests.
• Patient history reviews both medical and dental history.
• A chief complaint includes location, intensity duration, stimulus, relief, and spontaneity.
• Clinical exams include extraoral and intraoral elements.
• Extraoral exams include tenderness to palpation, swellings, and trismus.
• Intraoral exams consider soft tissues, fistula, swelling and teeth, extent of decay, and restorability.
• Clinical exams include palpation, percussion and mobility.
• Sensitivity during palpation relates to irreversible pulpitis/pulpal necrosis
• Sensitivity to percussion is usually related to irreversible pulpitis/pulpal necrosis.
• Increased mobility usually relates to pupal necrosis or the presence of infection
• Electric pulp and thermal testing are not reliable in primary and unformed permanent teeth and generally not used.
• Radiographic exams include primary visualizations in the furcation area.
• Bitewing x-rays suffice, but periapical x-rays may be needed.
• Other elements in a radiographic exam include furcation radiolucency, presence of a permanent successor, and extent of decay.
• For immature permanent teeth, a radiographic exam should include periapical area and require PA or BW x-rays.
• It should also consider extent of root formation, periapical radiolucency associated with pulpal necrosis, and extent of decay.
• Symptoms of reversible pulpitis include provoked pain of short duration, and it is relieved with OTC analgesics, brushing, or removal of stimulus.
• No radiolucencies or soft tissue pathology are on x-rays.
• Symptoms of irreversible pulpitis/necrosis include spontaneous, unprovoked pain, sinus tracts/fistulas and soft tissue inflammation unrelated to periodontal disease.
• Furcation or periapical radiolucency may appear on x-rays.
• Excessive mobility maybe present, but not related to trauma or exfoliation.
• Radiographic evidence of root resorption (external or internal) may be present.
• Spontaneous, nocturnal, or constant pain means that tissue may be irreversible or nonvital.
• Thermal, chemical or intermittent pain could indicate reversible and vital pulp.

Common Materials

• Common dental materials used include Calcium hydroxide, Dycal, glass ionomer cement (GIC), Vitrebond (3M ESPE), Lime-Lite (Pulpdent), Zinc oxide eugenol, IRM (Dentsply), Ferric sulfate, VisCoStat (Ultradent), Formocresol, Buckley's Formo Cresol (Sultan), Mineral Trioxide Aggregate (MTA), ProRoot MTA (Dentsply), Biodentine (Septodent), and Vitapex (Neo Dental).
• Dycal is a base and cavity liner that is self setting; setting time is 2.5-3.5 minutes.
• Dycal is used as a protective liner, indirect and direct pulp caps, pulpectomy, partial pulpotomy, apexification, or regenerative pulp therapy.
• Solubility is high with Dycal, seals poorly, and has low compressive strength.
• Glass ionomer cement (GIC), Vitrebond (3M ESPE), is a cavity liner and base, resin-modified and light cured, use as a protective liner and indirect pulp cap.
• It has inhibitory activity again cariogenic bacteria and placed over calcium hydroxide before restoring tooth and not directly on pulp.
• Lime-Lite (Pulpdent) is a cavity liner and base which is a resin-modified glass ionomer with calcium hydroxide and used as a liner for indirect pulp cap.
• Light cure for 20-30 secs and apply thin first layer (1/2 mm) with a Lime-Lite, avoid enamel margins.
• IRM (Detnsply) is a base and temporary restoration not placed directly on the pulp or in contact with a composite.
• It is employed for indirect pulp caps and pulpotomies, with a setting time of 5 mins.
• Ferric sulfate ViscoStat (Ultradent) is a hemostatic agent used for pulpotomies and left in the pulp chamber for 1-3 minutes and rinsed.
• Formocresol, Buckley's Formo Cresol (Sultan) is comprised of 19% formaldehyde, 35% cresol, 17.5% glycerine
• Formocresol is used as a gold standard for pulpotomy medicaments and is applied for 3-5 minutes using vapors on a cotton pellet.
• ProRoot MTA (Dentsply) is composed of portland cement, tricalcium silicate, dicalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite, gypsum and bismuth oxide.
• MTA can be white (preferred for front teeth) or gray, and is used in direct pulp cap, pulpotomy, pulpectomy, partial pulpotomy, apexification, and regenerative pulp therapy.
• Biodentine (Septodont) has tricalcium silicate, and aqueous calcium chloride, used for direct pulp cap, pulpotomy, or apexification and is for use in teeth with irreversible pulpitis.
• Vitapex (Neo Dental) possesses 40% iodoform, 30% calcium hydroxide, 22% silicone oil, used for pulpectomy and apexification and comes in premixed syringe.

Criteria for a Primary Tooth Root Filling

• Antiseptic.
• Resorbable.
• Harmless to permanent tooth bud.
• Radiopaque.
• Inserted easily.
• Removed easily.
• Biocompatible.