Pulp Therapy for Primary and Immature Permanent Teeth PDF 2023

BEST PRACTICES: PULP THERAPY Pulp Therapy for Primary and Immature Permanent Teeth Latest Revision How to Cite: American Academy of Pediatric Dentistry. Pulp therapy 2020...

BEST PRACTICES: PULP THERAPY Pulp Therapy for Primary and Immature Permanent Teeth Latest Revision How to Cite: American Academy of Pediatric Dentistry. Pulp therapy 2020 for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:457-65. Abstract This best practice supports clinicians in the diagnosis of pulp health or pathosis and provides evidence for various therapeutic interventions for pulp therapy in both primary and immature permanent teeth. The health status of pulp tissue determines which form of pulp therapy is indicated. Vital pulp therapies for primary teeth with normal pulp or reversible pulpitis include protective liner, indirect pulp treatment, direct pulp cap, and pulpotomy. Nonvital pulp treatment for primary teeth with irreversible pulpitis or necrotic pulp include pulpectomy and lesion stabilization/tissue repair. Vital pulp therapy for immature permanent teeth with a normal pulp or pulpitis include protective liners, apexogenesis, indirect pulp treatment, direct pulp cap, partial pulpotomy, and complete pulpotomy. Nonvital pulp treatment for permanent teeth includes conventional root canal treatment, apexification, and regenerative endodontics. Clinicians should familiarize them- selves with these pulp therapies and consider the value of each tooth in question, restorability of the tooth, and potential alternative treatment. This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and Scientific Affairs to offer updated information and guidance on pulp therapy for primary and immature permanent teeth. KEYWORDS: DENTAL PULP, ROOT CANAL THERAPY, ROOT CANAL PREPARATION, PULP CAPPING, APEXIFICATION Purpose Background The American Academy of Pediatric Dentistry (AAPD) intends The primary goal of pulp therapy is to maintain the integrity these recommendations to aid in the diagnosis of pulp health and health of the teeth and their supporting tissues while versus pathosis and to set forth the indications, objectives, maintaining the vitality of the pulp of a tooth affected by and therapeutic interventions for pulp therapy in primary and caries, traumatic injury, or other causes. Especially in young immature permanent teeth. permanent teeth with immature roots, the pulp is integral to continue apexogenesis. Long term retention of a permanent Methods tooth requires a root with a favorable crown/root ratio and Recommendations on pulp therapy for primary and immature dentinal walls that are thick enough to withstand normal permanent teeth were developed by the Clinical Affairs function. Therefore, pulp preservation is a primary goal for Committee – Pulp Therapy Subcommittee and adopted in treatment of the young permanent dentition. 1991.1 This document by the Council on Clinical Affairs is The indications, objectives, and type of pulp therapy are a revision of the previous version, last revised in 2014.2 This based on the health status of the pulp tissue which is classified revision included a new search of the PubMed /MEDLINE database using the terms: pulpotomy, pulpectomy, pulpec- ® as: normal pulp (symptom free and normally responsive to vitality testing), reversible pulpitis (pulp is capable of healing), tomy primary teeth, indirect pulp treatment (IPT), stepwise symptomatic or asymptomatic irreversible pulpitis (vital excavation, pulp therapy, pulp capping, pulp exposure, bases, inflamed pulp is incapable of healing), or necrotic pulp. 3 The liners, calcium hydroxide, formocresol, ferric sulfate, glass clinical diagnosis derived from:4-7 ionomer, mineral trioxide aggregate (MTA), bacterial 1. a comprehensive medical history. microleakage under restorations, lesion sterilization tissue 2. a review of past and present dental history and repair (LSTR), dentin bonding agents, resin modified glass treatment, including current symptoms and chief ionomers, and endodontic irrigants; fields: all. Papers for complaint. review were chosen from the resultant lists and from hand searches. When data did not appear sufficient or were ABBREVIATIONS inconclusive, recommendations were based upon expert and/ AAE: American Association of Endodontists. AAPD: American or consensus opinion including those from the 2007 joint Academy of Pediatric Dentistry. DPC: Direct pulp cap. IPT: Indirect symposium of the AAPD and the American Association of pulp therapy. ITR: Interim therapeutic restoration. LSTR: Lesion Endodontists (AAE) titled Emerging Science in Pulp Therapy: sterilization/tissue repair. MTA: Mineral trioxide aggregate. ZOE: New Insights into Dilemmas and Controversies (Chicago, Ill.) Zinc oxide eugenol. THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 457 BEST PRACTICES: PULP THERAPY 3. a subjective evaluation of the area associated with dental infection initially may require more frequent clinical the current symptoms/chief complaint by question- reevaluation. A radiograph of a primary tooth pulpectomy ing the patient/parent on the location, intensity, should be obtained immediately following the procedure.5 This duration, stimulus, relief, and spontaneity. can document the quality of the fill and help determine the 4. an objective extraoral examination as well as examina- tooth’s prognosis. This image also would serve as a comparative tion of the intraoral soft and hard tissues. baseline for future films (the type and frequency of which are 5. if obtainable, radiograph(s) to diagnose periapical or at the clinician’s discretion). Radiographic evaluation of primary periradicular changes. tooth pulpotomies should occur at least annually because the 6. clinical tests such as palpation, percussion, and success rate of pulpotomies diminishes over time.15 Bitewing mobility; however, electric pulp and thermal tests are radiographs obtained as part of the patient’s periodic compre- unreliable in immature permanent and primary teeth. hensive examinations may suffice. If a bitewing radiograph does not display the interradicular area, a periapical image is Teeth exhibiting provoked pain of short duration relieved indicated. Immature permanent teeth treated with pulp therapy with over-the-counter analgesics, by brushing, or upon the also should have close clinical and radiographic follow-up to removal of the stimulus and without signs or symptoms of confirm that pulp pathology is not developing.16 Isolation is irreversible pulpitis have a clinical diagnosis of reversible pulp- necessary to minimize bacterial contamination and to protect itis and are candidates for vital pulp therapy. Teeth diagnosed soft and hard tissues. Use of rubber dam isolation is considered with a normal pulp requiring pulp therapy or with reversible a gold standard17 for pulp treatment. When unable to use a pulpitis should be treated with vital pulp therapy.8-11 rubber dam, other effective isolation may be considered. Teeth exhibiting signs or symptoms such as a history of When a pulp exposure occurs and pulp therapy is indicated, spontaneous unprovoked pain, a sinus tract, soft tissue inflam- irrigants for pulp therapy should not come from dental mation not resulting from gingivitis or periodontitis, excessive unit water lines. The Centers for Disease Control and mobility not associated with trauma or exfoliation, furcation/ Prevention states “conventional dental units cannot reliably apical radiolucency, or radiographic evidence of internal/ deliver sterile water even when equipped with independent external resorption have a clinical diagnosis of irreversible water reservoirs containing sterile water because the water- pulpitis or necrosis and are candidates for nonvital pulp treat- bearing pathway cannot be reliably sterilized.”18 A single-use ment.12 Regenerative endodontics may be considered for im- disposable syringe should be used to dispense irrigants for mature permanent teeth with apical periodontitis, a necrotic pulp therapy. pulp, and immature apex.13 Primary teeth Recommendations Vital pulp therapy for primary teeth diagnosed with a normal All relevant diagnostic information, treatment, and treatment pulp or reversible pulpitis follow-up shall be documented in the patient’s record. Protective liner. A protective liner is a thinly-applied material Any planned treatment should include consideration of: placed on the dentin in proximity to the underlying pulpal 1. the patient’s medical history; surface of a deep cavity preparation, covering exposed dentin 2. the value of each involved tooth in relation to the tubules to act as a protective barrier between the restorative child’s overall development; material or cement and the pulp. Placement of a thin protec- 3. alternatives to pulp treatment; and tive liner such as MTA, trisilicate cements, calcium hydroxide, 4. restorability of the tooth. or other biocompatible material is at the discretion of the clinician.19,20 When the infectious process cannot be arrested by the Indications: In a tooth with a normal pulp when all caries treatment methods included in this section, bony support is removed for a restoration, a protective liner may be cannot be regained, inadequate tooth structure remains for placed in the deep areas of the preparation to minimize a restoration, or excessive pathologic root resorption exists, injury to the pulp, promote pulp tissue healing, and/or extraction should be considered.4,12 minimize postoperative sensitivity.21,22 This document is intended to recommend the best available Objectives: The placement of a liner in a deep area of the clinical care for pulp treatment, but the AAPD encourages preparation is utilized to preserve the tooth’s vitality, pro- additional research for consistently successful and predictable mote pulp tissue healing and tertiary dentin formation, and techniques using biologically-compatible medicaments for minimize bacterial microleakage.23 Adverse posttreatment vital and non-vital primary and immature permanent teeth. clinical signs or symptoms such as sensitivity, pain, or Pulp therapy requires periodic clinical and radiographic assess- swelling should not occur. ment of the treated tooth and the supporting structures.14 Postoperative clinical assessment generally should be performed Indirect pulp treatment. IPT is a procedure performed in a every six months and could occur as part of a patient’s periodic tooth with a deep caries lesion approximating the pulp but comprehensive oral examination. Patients treated for an acute without evidence of radicular pathology. “Indirect pulp 458 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY  BEST PRACTICES: PULP THERAPY treatment is a procedure that leaves the deepest caries adjacent tive dentin formation should result. There should be no to the pulp undisturbed in an effort to avoid a pulp exposure. radiographic signs of pathologic external or progressive This caries-affected dentin is covered with a biocompatible internal root resorption or furcation/apical radiolucency. material to produce a biological seal.”17 A radiopaque liner such There should be no harm to the succedaneous tooth. as a dentin bonding agent,24,25 resin modified glass ionomer,4 calcium hydroxide,25 or MTA (or any other biocompatible Pulpotomy. A pulpotomy is performed in a primary tooth material)26 is placed over the remaining carious dentin to when caries removal results in a pulp exposure in a tooth with stimulate healing and repair. The liner that is placed over the a normal pulp or reversible pulpitis or after a traumatic pulp dentin (calcium hydroxide, glass ionomer, or bonding agents) exposure12 and there is no radiographic sign of infection or does not affect the IPT success.27 The tooth then is restored pathologic resorption. The coronal pulp is amputated, pulpal with a material that seals the tooth from microleakage. hemorrhage is controlled, and the remaining vital radicular pulp Interim therapeutic restorations (ITR) with glass ionomer tissue surface is treated with a long-term clinically-successful cements may be used for caries control in teeth with caries medicament. Only MTA and formocresol are recommended lesions that exhibit signs of reversible pulpitis. The ITR can as the medicament of choice for teeth expected to be retained be removed once the pulp’s vitality is determined and, if for 24 months or more.17 Other materials or techniques such the pulp is vital, an indirect pulp cap can be performed.15,28 as ferric sulfate, lasers, sodium hypochlorite, and tricalcium Current literature indicates there is no conclusive evidence silicate have conditional recommendations.17 The AAPD’s Use that it is necessary to reenter the tooth to remove the residual of Vital Pulp Therapies in Primary Teeth with Deep Caries Lesions caries.29,30 As long as the tooth remains sealed from bacterial recommended against the use of calcium hydroxide for pulpo- contamination, the prognosis is good for caries to arrest and tomy.17 After the coronal pulp chamber is filled with a suitable reparative dentin to form to protect the pulp. 29-34 Indirect base, the tooth is restored with a restoration that seals the pulp treatment has been shown to have a higher success rate tooth from microleakage. If there is sufficient supporting than direct pulp cap (DPC) and pulpotomy in long term enamel remaining, amalgam or composite resin can provide a studies.8,10,15,25,27,35-40 IPT also allows for a normal exfoliation functional alternative when the primary tooth has a life span time. Therefore, IPT can be chosen instead of DPC or of two years or less.45-47 However, for multisurface lesions, a pulpotomy when the pulp is normal or has a diagnosis of stainless steel crown is the restoration of choice.17 reversible pulpitis and there is no pulp exposure. Indications: The pulpotomy procedure is indicated when Indications: IPT is indicated in a primary tooth with deep caries removal results in pulp exposure in a primary tooth caries that exhibits no pulpitis or with reversible pulpitis with a normal pulp or reversible pulpitis or after a traumatic when the deepest carious dentin is not removed to avoid pulp exposure,7 and when there are no radiographic signs of a pulp exposure.9,27 The pulp is judged by clinical and infection or pathologic resorption. When the coronal tissue radiographic criteria to be vital and able to heal from the is amputated, the remaining radicular tissue must be judged carious insult.17,27 to be vital without suppuration, purulence, necrosis, or Objectives: The restorative material should seal completely excessive hemorrhage that cannot be controlled by a cotton the involved dentin from the oral environment. The tooth’s pellet after several minutes.4 vitality should be preserved. No posttreatment signs or Objectives: The radicular pulp should remain asymptom- symptoms such as sensitivity, pain, or swelling should be atic without adverse clinical signs or symptoms such as sensi- evident. There should be no radiographic evidence of tivity, pain, or swelling. There should be no postoperative pathologic external or internal root resorption or other patho- radiographic evidence of pathologic external root resorption. logic changes. There should be no harm to the succedaneous Internal root resorption may be self-limiting and stable. The tooth. clinician should monitor the internal resorption, removing the affected tooth if perforation causes loss of supportive Direct pulp cap. When a pinpoint exposure (one millimeter bone and/or clinical signs of infection and inflammation.48-51 or less)17 of the pulp is encountered during cavity preparation There should be no harm to the succedaneous tooth. or following a traumatic injury, a biocompatible radiopaque base such as MTA26,41-43 or calcium hydroxide44 may be placed Nonvital pulp treatment for primary teeth diagnosed with irre- in contact with the exposed pulp tissue. The tooth is restored versible pulpitis or necrotic pulp with a material that seals the tooth from microleakage.8 Pulpectomy. Pulpectomy is a root canal procedure for pulp Indications: This procedure is indicated in a primary tooth tissue that is irreversibly inflamed or necrotic due to caries or with a normal pulp following a small (one millimeter or trauma. The root canals are debrided and shaped with hand less) pulp exposure of when conditions for a favorable or rotary files52 and then irrigated. A recent systematic review response are optimal.26,41-43 showed no difference in success when irrigating with chlor- Objectives: The tooth’s vitality should be maintained. No hexidine or one- to five-percent sodium hypochlorite or sterile posttreatment signs or symptoms such as sensitivity, pain, water/saline.53,54 Because it is a potent tissue irritant, sodium or swelling should be evident. Pulp healing and repara- hypochlorite must not be extruded beyond the apex.55 After the THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 459 BEST PRACTICES: PULP THERAPY canals are dried, a resorbable material such as non-reinforced a tooth is to be maintained for less than twelve months and zinc/oxide eugenol (ZOE),56,57 iodoform-based paste4, or a exhibits root resorption, LSTR is preferred to pulpectomy.53,54 combination paste of iodoform and calcium hydroxide58,59 is Objectives: Following treatment, the radiographic infectious used to fill the canals. A recent systematic review reports that process should resolve as evidenced by bone deposition in ZOE performed better long term than iodoform-based pastes.53 the pretreatment radiolucent areas and pretreatment clinical The tooth then is restored with a restoration that seals the signs and symptoms should resolve. tooth from microleakage. Clinicians should evaluate non-vital pulp treatments for success and adverse events clinically and Immature permanent teeth radiographically at least every 12 months.53,54 Vital pulp therapy for teeth diagnosed with a normal pulp or Indications: A pulpectomy is indicated in a primary tooth reversible pulpitis with irreversible pulpitis or necrosis or a tooth treatment Protective liner. A protective liner is a thinly-applied material planned for pulpotomy in which the radicular pulp exhibits placed on the pulpal surface of a deep cavity preparation, clinical signs of irreversible pulpitis or pulp necrosis (e.g., covering exposed dentin tubules, to act as a protective barrier suppuration, purulence) The roots should exhibit minimal between the restorative material or cement and the pulp. Place- or no resorption. When there is no root resorption present, ment of a thin protective liner such as MTA, trisilicate pulpectomy is recommended over LSTR.53,54 cements, calcium hydroxide, or other biocompatible material Objectives: Following treatment, the radiographic infectious is at the discretion of the clinician.19 The liner must be followed process should resolve in six months as evidenced by bone by a well-sealed restoration to minimize bacterial leakage from deposition in the pretreatment radiolucent areas, and pre- the restoration-dentin interface.23 treatment clinical signs and symptoms should resolve within Indications: In a tooth with a normal pulp, when caries is a few weeks. There should be radiographic evidence of suc- removed for a restoration, a protective liner may be placed cessful filling without gross overextension or underfilling.57-59 in the deep areas of the preparation to minimize pulp injury, The treatment should permit resorption of the primary promote pulp tissue healing, and/or minimize postoperative tooth root and filling material to permit normal eruption of sensitivity. the succedaneous tooth. There should be no pathologic root Objectives: The placement of a liner in a deep area of the resorption or furcation/apical radiolucency. preparation is utilized to preserve the tooth’s vitality, promote pulp tissue healing, and facilitate tertiary dentin formation. Lesion sterilization/tissue repair. LSTR is a procedure that This liner must be followed by a well-sealed restoration usually has no instrumentation of the root canals but, instead, to minimize bacterial leakage from the restoration-dentin an antibiotic mixture is placed in the pulp chamber which is interface.23 Adverse posttreatment signs or symptoms such intended to disinfect the root canals.53,54 After opening the as sensitivity, pain, or swelling should not occur. pulp chamber of a necrotic tooth, the canal orifices are enlarged using a large round bur to create medication Apexogenesis (root formation). Apexogenesis is a histological receptacles. The walls of the chamber are cleaned with term used to describe the continued physiologic development phosphoric acid and then rinsed and dried.60 A three antibi- and formation of the root’s apex. Formation of the apex in otic mixture of clindamycin, metronidazole, and ciprofloxacin vital young permanent teeth can be accomplished by im- is combined with a liquid vector of polyethylene glycol and plementing the appropriate vital pulp therapy described in macrogol to form a paste placed directly into the medication this section (i.e., indirect pulp treatment, direct pulp capping, receptables and over the pulpal floor.60 It then is covered partial pulpotomy for carious exposures and traumatic with a glass-ionomer cement and restored with a stainless steel exposures). crown.60 Previous studies have used minocycline in place of clindamycin61, but there are concerns about staining when a Indirect pulp treatment. IPT is a procedure performed in a tetracycline-like drug is used.62 Although similar success rates tooth with a diagnosis of reversible pulpitis and deep caries have been reported whether minocycline or clindamycin is that might otherwise need endodontic therapy if the decay was used62, a more recent systematic review concluded statistically completely removed.12 In recent years, rather than completing significant less success using a tetracycline mix versus a mix the caries removal in two appointments, the focus has been to without tetracycline53. Therefore, the AAPD’s Use of Non-Vital excavate as close as possible to the pulp, place a protective liner, Pulp Therapies in Primary Teeth recommends antibiotic and restore the tooth without a subsequent reentry to remove mixtures used in LSTR should not include tetracycline.54 any remaining affected dentin.63,64 The risk of this approach is Indications: LSTR is indicated for a primary tooth with either an unintentional pulp exposure or irreversible pulpitis.64 irreversible pulpitis or necrosis or a tooth treatment planned When there is concern for pulp exposure, the step-wise excava- for pulpotomy in which the radicular pulp exhibits clinical tion of deep caries may be considered.16 This approach involves signs of irreversible pulpitis or pulp necrosis (e.g., suppura- a two-step process. The first step is the removal of carious tion, purulence). Root resorption and strategic tooth position dentin along the dentin-enamel junction and excavation of in the arch should be considered prior to treatment. When only the outermost infected dentin, leaving a carious mass 460 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY  BEST PRACTICES: PULP THERAPY over the pulp. The objective is to change the cariogenic surrounding dentin followed by a layer of light-cured resin- environment in order to decrease the number of bacteria, modified glass ionomer.69 A restoration that seals the tooth close the remaining caries from the biofilm of the oral cavity, from microleakage is placed. and slow or arrest the caries development.65-67 This interim Indications: A partial pulpotomy is indicated in a young restoration should be able to be maintained for up to 12 permanent tooth for a carious pulp exposure in which the months.16 The second step is the removal of the remaining pulp bleeding is controlled within several minutes. The caries and placement of a final restoration. Critical to both tooth must be vital, with a diagnosis of normal pulp or steps of excavation is the placement of a well-sealed reversible pulpitis. restoration.23 A recent meta-analysis has shown that long term Objectives: The remaining pulp should continue to be vital success rates are equivalent for partial caries removal or step- after partial pulpotomy. There should be no adverse clini- wise caries removal with greater than 96 percent of teeth cal signs or symptoms such as sensitivity, pain, or swelling. treated remaining vital after two years.68 There should be no radiographic sign of internal or external Indications: IPT is indicated in a permanent tooth with resorption, abnormal canal calcification, or periapical radio- deep caries that exhibits no pulpitis or has been diagnosed lucency postoperatively. Teeth having immature roots should as reversible pulpitis when the deepest carious dentin is not continue normal root development and apexogenesis. removed to avoid a pulp exposure. The pulp is judged by clinical and radiographic criteria to be vital and able to heal Partial pulpotomy for traumatic exposures (Cvek pulpotomy). from the carious insult. The partial pulpotomy for traumatic exposures is a procedure Objectives: The intermediate and/or final restoration should in which the inflamed pulp tissue beneath an exposure that seal completely the involved dentin from the oral environ- is four millimeters or less in size76 is removed to a depth of ment. The vitality of the tooth should be preserved. No one to three millimeters or more to reach the deeper healthy posttreatment signs or symptoms such as sensitivity, pain, tissue. While literature indicates that a Cvek pulpotomy may or swelling should be evident. There should be no radio- be completed up to nine days after an exposure, there is no graphic evidence of internal or external root resorption or evidence on tooth outcomes with longer periods of waiting other pathologic changes. Teeth with immature roots should time.76 Pulp bleeding is controlled using irrigants such as show continued root development and apexogenesis. sodium hypochlorite or chlorhexidine,70,71 and the site then is covered with calcium hydroxide77,78 or MTA12,79. MTA may Direct pulp cap. When a small exposure of the pulp is cause tooth discoloration.80,81 The two versions (light and encountered during cavity preparation and after hemorrhage gray) have been shown to have similar properties.82,83 While control is obtained, the exposed pulp is capped with a calcium hydroxide has been demonstrated to have long-term material such as calcium hydroxide44,69 or MTA69 prior to success, MTA results in more predictable dentin bridging placing a restoration that seals the tooth from microleakage.23 and pulp health.75 MTA (at least 1.5 millimeters thick) Indications: Direct pulp capping is indicated for a perma- should cover the exposure and surrounding dentin, followed nent tooth that has a small carious or mechanical exposure by a layer of light-cured resin-modified glass ionomer.79 A in a tooth with a normal pulp. restoration that seals the tooth from microleakage is placed. Objectives: The tooth’s vitality should be maintained. No Indications: This pulpotomy is indicated for a vital, posttreatment clinical signs or symptoms of sensitivity, traumatically-exposed, young permanent tooth, especially pain, or swelling should be evident. Pulp healing and one with an incompletely formed apex reparative dentin formation should occur. There should Objectives: The remaining pulp should continue to be vital be no radiographic evidence of internal or external root re- after partial pulpotomy. There should be no adverse clinical sorption, periapical radiolucency, abnormal calcification, or signs or symptoms of sensitivity, pain, or swelling. There other pathologic changes. Teeth with immature roots should should be no radiographic signs of internal or external re- show continued root development and apexogenesis. sorption, abnormal canal calcification, or periapical radio- lucency postoperatively. Teeth with immature roots should Partial pulpotomy for carious exposures. The partial pulpotomy show continued normal root development and apexogenesis. for carious exposures is a procedure in which the inflamed pulp tissue beneath an exposure is removed to a depth of Complete pulpotomy. A complete or traditional pulpotomy one to three millimeters or deeper to reach healthy pulp involves complete surgical removal of the coronal vital pulp tissue. Pulp bleeding must be controlled by irrigation with tissue followed by placement of a biologically acceptable ma- a bacteriocidal agent such as sodium hypochlorite or terial in the pulp chamber and restoration of the tooth.6 chlorhexidine51,70,71 before the site is covered with calcium Compared to the traditionally-used calcium hydroxide, hydroxide12 or MTA.72-74 While calcium hydroxide has been MTA and tricalcium silicate exhibit superior long-term seal demonstrated to have long-term success, MTA results in and reparative dentin formation leading to a higher success more predictable dentin bridging and pulp health.75 MTA (at rate.84-86 least 1.5 millimeters thick) should cover the exposure and THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 461 BEST PRACTICES: PULP THERAPY Indications: A full pulpotomy is indicated in immature canal space can be filled with MTA or composite resin instead permanent teeth with cariously exposed pulp as an interim of gutta percha to strengthen the tooth against fracture.6 procedure to allow continued root development (apexogen- Indications: This procedure is indicated for non-vital esis). It also may be performed as an emergency procedure permanent teeth with incompletely formed roots. for temporary relief of symptoms until a definitive root Objectives: This procedure should induce root end closure canal treatment can be accomplished.6 (apexification) at the apices of immature roots or result in Objectives: Full pulpotomy procedure in a vital permanent an apical barrier as confirmed by clinical and radiographic tooth aims to preserve the vitality of remaining radicular evaluation. Adverse posttreatment clinical signs or symptoms pulp.3 The objective is to prevent adverse clinical signs and of sensitivity, pain, or swelling should not be evident. There symptoms, obtain radiographic evidence of sufficient root should be no radiographic evidence of external root resorp- development for endodontic treatment, prevent breakdown tion, lateral root pathosis, root fracture, or breakdown of of periradicular tissues, and to prevent resorptive defects periradicular supporting tissues during or following therapy. or accelerated canal calcification as determined by periodic The tooth should continue to erupt, and the alveolus should radiographic evaluation.6 continue to grow in conjunction with the adjacent teeth. Nonvital pulp treatment Regenerative endodontics. Regenerative endodontics is defined Pulpectomy (conventional root canal treatment). Pulpectomy as biologically-based procedures designed to physiologically in apexified permanent teeth is conventional root canal replace damaged tooth structure, including dentin and root (endodontic) treatment for exposed, infected, and/or necrotic structures, as well as the pulp-dentin complex.88 The goals of teeth to eliminate pulp and periradicular infection. In all the regenerative procedure are elimination of clinical symptoms/ cases, the entire roof of the pulp chamber is removed to gain signs and resolution of apical periodontitis in teeth with a access to the canals and eliminate all coronal pulp tissue. necrotic pulp and immature apex.89 Thickening of the canal Following cleaning, disinfection, and shaping of the root canal walls and/or continued root maturation is an additional goal.89 system, obturation of the entire root canal is accomplished The difference between regenerative endodontic therapy and with a biologically-acceptable semi-solid or solid filling nonsurgical conventional root canal therapy is that the disin- material.6 fected root canal space in the former therapy is filled with the Indications: Pulpectomy or conventional root canal treat- host’s own vital tissue and the canal space in the latter therapy ment is indicated for a restorable permanent tooth with a is filled with biocompatible foreign materials. closed apex that exhibits irreversible pulpitis or a necrotic Indications: This procedure is indicated for nonvital perma- pulp. For root canal-treated teeth with unresolved peri- nent teeth with incompletely formed roots. radicular lesions, root canals that are not accessible from the Objectives: This procedure should result in increased width conventional coronal approach, or calcification of the root of the root walls and may lead to increase in root length, canal space, endodontic treatment of a more specialized both confirmed by radiographic evaluation. Adverse post- nature may be indicated. treatment clinical signs or symptoms of sensitivity, pain, Objectives: There should be evidence of a successful filling or swelling should not be evident. There should be no without gross overextension or underfilling in the presence radiographic evidence of external root resorption, lateral of a patent canal. There should be no adverse posttreatment root pathosis, root fracture, or breakdown of periradicular signs or symptoms such as prolonged sensitivity, pain, or supporting tissues during or following therapy. The tooth swelling, and there should be evidence of resolution of should continue to erupt, and the alveolus should continue pretreatment pathology with no further breakdown of peri- to grow in conjunction with the adjacent teeth. radicular supporting tissues clinically or radiographically. References Apexification (root end closure). Apexification is a method of 1. American Academy of Pediatric Dentistry. Pulp therapy inducing root end closure of an incompletely formed non-vital for primary and young permanent teeth. In: American permanent tooth by removing the coronal and non-vital Academy of Pediatric Dentistry Reference Manual 1991- radicular tissue just short of the root end and placing a bio- 1992. Chicago, Ill.: American Academy of Pediatric compatible agent such as calcium hydroxide in the canals for Dentistry; 1991:53-7. two weeks to one month to disinfect the canal space.16 Root 2. American Academy of Pediatric Dentistry. Pulp therapy end closure is accomplished with an apical barrier such as for primary and immature permanent teeth. Pediatr Dent MTA.6 In instances when complete closure cannot be accom- 2014;36(special issue):242-50. plished by MTA, an absorbable collagen wound dressing87 can 3. American Association of Endodontists Special Committee be placed at the root end to allow MTA to be packed within to Revise the Glossary. Glossary of Endodontic Terms. the confines of the canal space. Gutta percha is used to fill 10th ed. Chicago, Ill.: American Association of Endodon- the remaining canal space. If the canal walls are thin, the tists; 2020. Available at: “https://www.aae.org/specialty/ clinical-resources/glossary-endodontic-terms/”. Accessed August 3, 2020. 462 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY  BEST PRACTICES: PULP THERAPY 4. Fuks A, Kupietzky A, Guelmann M. Pulp therapy for the 18. Centers for Disease Control and Prevention. Summary of primary dentition. 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