Pulp Therapy Treatment Options

• Pulp Therapy II includes treatment for children by Beth Rosenberg.

Treatment Options

• Factors to consider when planning treatment are medical history, tooth value in relation to overall development, time until exfoliation of 2nd primary molars in young children and primary teeth without a successor, alternative pulp therapy, extraction and space maintenance, restorability, and finances.

Vital Pulp Therapy

• Vital pulp therapy options include; protective liner, indirect and direct pulp cap, pulpotomy, partial pulpotomy for permanent teeth only, apexogenesis for permanent teeth only, and regenerative pulp therapy for permanent teeth only.

Non-Vital Pulp Therapy

• Non-vital pulp therapy options include: pulpectomy, apexification (permanent teeth only), and root canal therapy (permanent teeth only).

Extraction

• Extraction can be a treatment alternative if bone support cannot be regained, the tooth is non-restorable, infection cannot be arrested by pulp therapy, or there is excessive pathologic root resorption.
• Space maintenance should be considered after extractions.

Clinical Procedures

• Clinical procedures include; protective liner, indirect pulp cap, direct pulp cap, pulpotomy, and pulpectomy.
• Pulp therapy should always be performed under rubber dam isolation.
• Treatment plans should confirmed before the treatment, and the tooth should still be restorable, with no worsening symptoms or soft tissue pathology.

Protective Liner

• A protective liner is indicated when teeth have a deep preparation, normal pulp, and no pulp exposure.
• A thin protective layer is placed over deep portions of the preparation.
• Calcium hydroxide, dentin bonding agent, or glass ionomer can be used.

Indirect Pulp Cap

• Deep caries approaching the pulp, reversible pulpitis, and no soft tissue pathology or radiolucencies on x-ray are indications for an indirect pulp cap.
• Procedure involves removing decay from walls and gingival floor, leaving deep caries near pulp, removing all infected soft dentin and leaving harder affected dentin
• A glass ionomer, calcium hydroxide, or ZOE is placed over the remaining decay for final restoration.
• Indirect pulp cap shows better success than pulpotomy.
• The preferred treatment for normal pulp or reversible pulpitis with caries near but not into the pulp chamber.

Indirect Pulp Cap Continued

• For primary teeth, a one-step process is preferred.
• Current literature shows there is no conclusive evidence that it is necessary to re-enter the tooth to remove the residual caries.
• The prognosis is good for caries to arrest if the tooth remains sealed from bacterial contamination, reparative dentin will form to protect the pulp.
• For permanent teeth, a two-step process managing reversible pulpitis has proven successful without pulpal perforation.
• In the two-step process, excavation of carious dentin occurs in the dentin-enamel junction (DEJ), and outermost infected dentin, leaving a carious mass over the pulp.
• The interval between these steps is 3-6 months, which forms tertiary dentin and a definitive pulpal diagnosis
• Placement of a well-sealed restoration is critical to both excavation steps.

Direct Pulp Cap

• Indications for direct pulp cap include the following for primary teeth: small mechanical or traumatic exposure, normal pulp, no symptoms, pathology, or radiolucencies, and not for carious exposure.
• The indications for permanent teeth are: small carious or mechanical exposure, normal pulp, and no symptoms, pathology, or radiolucencies.
• Make sure decay is removed as part of the procedure.
• Perform pulpotomy if decay remains in primary teeth.
• Place MTA or calcium hydroxide over the pulp exposure.
• Place well-sealed definitive restoration.

Pulpotomy

• Pulpotomies are indicated only for primary teeth with carious or traumatic exposure, normal pulp or reversible pulpitis, no soft tissue lesions, and no radiolucencies on x-rays.
• Procedure includes establishing outline form of prep, may not need pulpotomy
• You have to excavate carious dentin from lateral walls and gingival floor first, then leave the pulpal wall for last.
• If carious pulp exposure occurs establish access to the pulp chamber, unroof entire pulp chamber, and remove all overhanging dentinal tissue.
• As part of the procedure: amputate coronal pulp using slow speed or spoon, control hemorrhage and clean pulp chamber using sterile water and pressure with cotton pellets, confirm treatment plan by examining the radicular tissue; there should be no suppuration/ purulence, bleeding should be present, and there should be no excessive hemorrhage.
• Apply medicament like Formocresol, ferric sulfate, sodium hypochlorite, electrosurgery, or calcium hydroxide
• Check for hemostasis, require pulpectomy or extraction if not controlled after 2nd application.
• Place ZOE in the pulp chamber. and definitively must be well-sealed.
• SSC restoration is the choice. Place amalgam or composite if the tooth will exfoliate within 2 years

Pulpectomy

• Pulpectomies are indicated when irreversible pulpitis or necrosis is present.
• Pulpectomies are also performed on primary teeth when signs of excessive hemorrhage that cannot be controlled with pressure, suppuration, or purulence is present after pulpotomy.
• The procedure begins with a pulpotomy.
• Once pulpal tissue in the chamber is removed, the tissue is removed in canals using thin hand files for primary molars.
• Irrigate canals with 1% sodium hypochlorite or chlorhexidine, be careful not to extrude irrigation solution beyond apex.
• Do not use sterile water irrigation because it will not disinfect area.
• Dry canals with paper points.
• Place resorbable material in canals,(primary only) such as: ZOE, lodoform-based paste KRI, or Combination paste of iodoform and calcium hydroxide
• Place ZOE or MTA in chamber and restore with well-sealed restoration

Pain and Pulp Status

• Spontaneous, nocturnal, and constant pain indicate irreversible pulp and a nonvital tooth: pulpectomy is indicated.
• Thermal, chemical, and intermittent pain indicate reversible pulp and vital tooth: pulpotomy is indicated.

Follow Up

• Follow up includes clinical and radiographic exams.
• Recall appointments are part of follow ups every 6 months.
• More frequent follow up is indicated in acute infections
• No pain, soft tissue lesions of normal mobility, or any issues indicates good health
• Radiographic exam should include X-ray taken immediately after pulpectomy as the baseline and check fill.
• At least annual radiographs of primary tooth pulpotomies. can have bitewings but periapicals are needed if furcation can not be assessed.
• Periapicals should be taken of permanent teeth.