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Clinical Guideline 5 - Version 3

Valid to: November 2012

Pulp Treatments in Deciduous Teeth


Purpose
Evidence-based clinical guidelines are intended to provide guidance, and are not a standard
of care, requirement, or regulation. However, the application of clinical guidelines in
publicly-provided oral health services allows for consistency to occur across large patients
cohorts with a variety of oral health clinicians.
Conservative care for the deciduous dentition is primarily undertaken to ensure:
Restoration of damaged teeth to healthy function;
Management of pain/discomfort;
Prevention of orthodontic complications;
Prevention of demineralisation of permanent abutting teeth; and
Maintenance of aesthetics
Pulpal treatment for deciduous teeth includes maintenance of pulp vitality, mummification
of coronal pulpal tissue with maintenance of vitality of radicular pulp (pulpotomy) or
pulpectomy.
These clinical guidelines aim to provide criteria for selection of teeth suitable for
pulpotomies and pulpectomies. This paper will also describe the clinical steps that are
required when performing deciduous pulp treatments.

Guideline
Clinical considerations
When dental caries has extended to the pulp chamber of a deciduous tooth, careful
assessment needs to be made regarding efficacy of treatment options, the expected life
span of the tooth, location of its permanent successor and its restorability. The decision to
perform pulpal therapy on a deciduous tooth requires a thorough history of symptoms, and
a complete oral examination including radiographs (particularly a periapical radiograph of
the affected tooth). In some situations, dental therapists (DT) may refer the patient to a
dentist for assessment and/or treatment.
Contra-indications to Pulp Therapy:
Medically Compromised Patients Relevant medical factors need to be considered
in treatment planning for pulpal therapy. Pulp therapy is contraindicated in patients
with congenital cardiac disease; immunosuppression and other children with poor
healing ability (eg. uncontrolled diabetes)
Restorability of the crown Any pulpal treatment requires the formation of an
adequate coronal seal. A tooth that cannot be adequately restored is not suitable for
pulpal therapy. The restoration of choice for pulp-treated deciduous teeth is a
preformed metal crown (Stainless Steel Crown)
Inability to place rubber dam Rubber dam is mandatory for all pulpal treatment.
Inability to isolate the tooth with a rubber dam is a contraindication to pulp therapy.
Dental Age of Patient - There is little rationale for retention of deciduous teeth once
the permanent successor has commenced eruption. This is evidenced radiographically
when the tip of the crown of the succedaneous tooth has broken through bony crypt.
As such, it is imperative that an assessment of the dental age of the patient is
undertaken and considered in treatment planning. Radiographs should be taken to
confirm the presence of the succedaneous teeth if dental age is the prime reason for
extraction of the deciduous tooth.

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Clinical Guideline 5 - Version 3


Valid to: November 2012

Behaviour management The child should exhibit appropriate behaviour in order to


ensure successful pulp treatment of deciduous teeth in the dental chair.

Diagnosis
The table below details diagnostic criteria for pulp conditions. It is essential to determine
the health or inflammation of the pulp and whether the pulp is partially or totally involved
through a series of diagnostic criteria, understanding that these are generally correct but
that exceptions do exist.
Diagnostic factors

Increased mobility
Tenderness on percussion
Sensitivity
Radiographic or pathologic changes
(thickened
periodontal
ligament
space, or radicular disease)
Excessive bleeding at the exposure
Toothache

Diagnostic criteria indicative of:


Partial
Total chronic
Pulpal necrosis
reversible
pulpitis
chronic pulpitis
No
Yes
Yes
No
Yes
Often
Yes
Yes
Unlikely
No
Often
Yes
No
Sometimes
upon
stimulation

Often
Yes

No
Often

Adapted from: Schrder U Pedodontic endodontics, in Pediatric Dentistry A Clinical


Approach, Munksgaard 2001, p214
A pulp is healthy when exposed by trauma, and can generally be maintained by appropriate
dental treatment. A caries-exposed pulp is always chronically inflamed, either partially or
totally, or may be necrotic. Teeth with the symptoms of total chronic pulpitis are not
expected to heal. Extraction or pulpectomy are the preferred treatments for teeth with
total chronic pulpitis or pulpal necrosis.
Treatment Options
Pulp capping
Rationale
Pulp capping has little success in the management of carious pulp exposures in the
deciduous dentition and therefore should not be performed.
Pulpotomy
Rationale
A pulpotomy involves removal of vital coronal pulp tissue and maintenance of healthy apical
pulpal tissue via placement of a medicament.
Medicaments
Formocresol is a medicament used in the treatment of cariously exposed vital molars and
has been in use for approximately 100 years. Formocresol was first used in the early 1900s
on permanent molars and was known as Buckleys solution. Its use on primary (deciduous)
teeth was first described in 1930. The solution used then contained 19% formaldehyde
v/v. In recent times, the concentration of formaldehyde in the solution has decreased to 1
in 5. This is known as Formocresol Mitis and contains 4% v/v formaldehyde solution. Its
clinical and radiographic success rate in the Mitis concentration is over 90%. The
formocresol technique is considered to be the most universally taught pulp therapy
technique for primary teeth for over sixty years.
However, a number of recent studies have demonstrated serious adverse effects associated
with the Formocresol pulpotomy. These include:

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Clinical Guideline 5 - Version 3


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1. chronic inflammation and necrosis of the radicular pulp (Berger, 1972; Rolling and
Lambjerg-Hansen, 1978);
2. systemic distribution from the pulpotomy site (Myers et al 1978);
3. toxic, mutagenic and/or carcinogenic properties of formaldehyde and cresol (Judd
and Kennedy 1987; Levin 1998; Lewis 1998; Ibrecevic and Al-Jame, 2003);
4. enamel defects in permanent successors associated with formocresol pulpotomies in
primary teeth (Pruhs et al, 1977).
The most appropriate alternative pulpotomy agent is Ferric Sulphate (Ibercevic and AlJame, 2003), as in clinical trials it has similar success to Formocresol (Papagiannoulis,
2002).
Ferric Sulphate (Viscostat):
The most important finding from the reviewed studies was that ferric sulphate gives very
good clinical and radiographic results with high tooth survival rates and with no statistically
significant differences from that of formocresol. The review also found that internal
resorption is a common radiographic finding in both ferric sulphate and formocresol
treatments with no statistically significant differences between them.
Calcium hydroxide is the only medicament that promotes biological healing and the
formation of a hard-tissue barrier over the amputated pulp. Its main disadvantage appears
to be the complication of internal resorption, and this appears to be associated with the
presence of a blood clot at the site of the amputation. Calcium hydroxide pulpotomies have
a success rate of approximately 60%, and careful investigation of the diagnostic criteria for
pulpal conditions must be undertaken. Calcium hydroxide, if used, should be in the form of
methyl cellulose (e.g. Pulpdent ).
Based on these results DHSV recommends the use ferric sulphate (Viscostat) as
the medicament of choice, rather than formocresol, for pulpotomies of primary
teeth.
Selection Criteria
Pulpotomies are indicated for teeth that have pulpal tissue that is minimally and reversibly
inflamed. These teeth exhibit normal mobility, are not tender to percussion and do not
exhibit pathological changes as diagnosed by radiograph. They may show some sensitivity
and infrequently a mild toothache upon stimulation. During the procedure, there should be
little haemorrhage at the site of exposure.
Pulpotomies are contra-indicated in the presence of swelling, fistula, mobility, external root
resorption, internal root resorption, periapical or furcation radiolucency, or excessive
haemorrhage from the pulpal tissue, and the presence of systemic medical conditions e.g.
congenital heart disease, rheumatic heart disease
Methodology for vital pulpotomy
The tooth should be anaesthetised, and rubber dam placed. All caries is removed and the
enamel trimmed back to give an adequate access cavity. The coronal pulp tissue adjacent
to a carious exposure should be removed as it is generally inflamed and contains bacteria.
The abnormal tissue immediately adjacent to the exposure site of teeth with partial chronic
pulpitis should also be removed. Extensive bleeding after caries removal and coronal pulp
amputation indicates a more extensive pulpal involvement and therefore has a questionable
prognosis for pulpotomy as a treatment option.
After removal of the pulp chamber roof with a bur, an excavator is used to excise the pulp
down to the canal orifices. Sterile cotton pellets should be placed into the excavated

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coronal pulp chamber under light pressure to control haemorrhage. After the completion of
the pulpotomy the pulpal stumps are treated with a pulpotomy agent.
In the ferric sulphate pulpotomy, ferric sulphate (Viscostat) is applied with a micro-brush
(or on a cotton pellet) to the pulpal stumps for 15 seconds with a gentle rubbing
motion. Any surplus is then removed with a moist cotton pellet. Once Haemostasis has
been achieved the pulpal stumps are covered with a layer of zinc oxide eugenol and the
tooth is restored with a stainless steel crown for all multisurface cavities. For small occlusal
openings composite resin restorations may be used (Papagiannoulis, 2002)
Access to Ferric Sulphate (Viscostat)
Ferric Sulphate (Viscostat) is available at Dental Logistics in 1.20 ml skinny syringes. and
is supplied in boxes containing 20 syringes each. A box of 20 syringes should last a single
chair clinic approximately 18-20 months depending on the number of vital pulpotomies
undertaken in the clinic per year.
The skinny syringes are not to be used directly onto the tooth being treated. A small
amount of Viscostat gel should be dispensed from the skinny syringe onto a mixing pad
or into a Dappen dish and then applied to the tooth using a microbrush/applicator tip/cotton
pellet.
Review of teeth treated with a pulpotomy
If successful, the treated tooth should be asymptomatic. Pain, swelling, mobility, fistulae,
or radiographic changes, e.g. radiolucency at apex or furcation, or internal resorption,
suggest clinical failure. Pulpal therapy cases should be reviewed using radiographic
assessment of the tooth every 12 months.
Pulpectomy
Rationale
A pulpectomy involves the removal of Coroval tradicular necrotic pulpal tissue and its
replacement by a resorbable medicament.
There is a range of views in the literature regarding the value of treating necrotic pulps in
primary teeth. In Scandinavia, these teeth are generally extracted. In the United States,
pulpectomies are generally indicated only for primary teeth without a permanent successor
and restorable primary second molars prior to the eruption of the first permanent molar.
Dental Therapists (DT) are generally the initial point of contact for paediatric patients. DTs
will therefore make decisions regarding which patients are to be referred to a dental officer
(DO) for proposed pulpectomy treatment within the broad parameters discussed within this
paper. The final treatment decision however, rests with the DO. First stage preparation of
the tooth for pulpectomy is generally undertaken by the DT. This involves removal of
necrotic tissue, irrigation, placement of cotton pellet and placement of temporary
restoration.
Selection Criteria
The decision to perform a pulpectomy should only follow a thorough assessment, including
history taking, examination and peri-apical radiograph.
Indications
Evidence of pulpal necrosis
Hyperaemic pulp
Contraindications
Restorability of crown
The success of a pulpectomy is reliant upon a number of factors, fundamental amongst
which is the capacity to obtain an adequate coronal seal. Therefore a tooth which cannot

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Clinical Guideline 5 - Version 3


Valid to: November 2012
adequately be restored, either using plastic restorative materials or preformed metal
crowns (stainless steel crowns), is not suitable for pulpectomy.
Perforation of floor of pulp chamber.
Any perforation of the floor of the pulp chamber (mechanical or pathological) will
render a tooth unsuitable for conservative treatment and requires extraction.
Root resorption
The prognosis for teeth which have undergone root resorption is poor, particularly if
greater than one-third of the root is resorbed in the case of external resorption; or if
there is any evidence of internal resorption.
Tooth Type
Anterior deciduous teeth
When undertaken, these generally demonstrate a lower success rate than those undertaken
on posterior deciduous teeth.
Pulpectomies should not be performed on anterior teeth, except perhaps in the very young
(1-4 years).
First deciduous molars
Space loss, when it does occur following extraction of deciduous teeth, is greatest in the
site of the second deciduous molar, particularly if the first permanent molar is unerupted.
The more anterior the site of tooth loss, the less the mesial migration of posterior teeth. As
such, pulpectomy of a first deciduous molar is not generally indicated, particularly when
first permanent molars have erupted and are in occlusion. In addition, if cuspal
interference prevents tooth migration, interdental spaces are present, the permanent
successor will erupt within six months, or arch space analysis indicates a malocclusion is
unlikely, extraction is preferred without the need for a space maintainer.

Bony Loss including furcation involvement


Significant apical bone loss, including lesions which may be considered cystic,
particularly that associated with increased dental mobility or extending to the
permanent tooth bud, would be a contra-indication for a pulpectomy. In addition,
extensive loss of bone from the furcation area will generally render the tooth
unsuitable for pulpectomy.

Unresolved draining sinus


A persistent sinus is generally accompanied by bone loss. Pulpectomy will generally
fail in these situations and should therefore not be undertaken.

Oral health status


Careful consideration should be given to providing a pulpectomy for a child whose oral
health is generally poor or where parents show little motivation or interest in making
improvements. In this situation, extraction would be the most appropriate option.

Behaviour Management
As the decision to provide pulpectomy commits the patient to a minimum of two
lengthy appointments and the treatment is technique sensitive, it is essential that the
child exhibits appropriate behaviour in the dental chair for a pulpectomy or indeed for
any pulpal treatment to be undertaken.

Medical Conditions
Pulpectomies are contra-indicated in children with systemic conditions including
congenital heart disease, leukemia or long-term cortico-steroid therapy.

Pain
Persistent pain, which has not resolved following initial pulpectomy treatment,
indicates that the tooth is not suitable for further pulpal treatment.

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Clinical Guideline 5 - Version 3


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Rubber Dam
If the clinical situation is such that rubber dam cannot be applied, then a pulpectomy
procedure or any pulpal therapy should not be commenced.

Treatment under general anaesthetic


In addition, if the child requires a general anaesthetic for dental treatment,
pulpectomies should not be undertaken due to their variable long-term success rate.

Methodology
Local anaesthesia (LA) is not always required as the tooth is necrotic. However, there may
be remnants of some vital tissue within the roots, so LA is advisable. Rubber dam must be
placed to isolate the tooth as a relatively clean field is required. The procedure should be
performed following viewing of a recent peri-apical radiograph.
All caries should be removed with high and then slow speed handpieces, and access to the
pulp chamber widened with a large round bur. The pulp canals should be debrided with
hand files to approximately 75% of the estimated length of the tooth roots. The canals
should be filed up to 3 sizes from the initial file and irrigated with Miltons solution. The
canals should be dried with paper points.
The canals should then be filled with non-reinforced ZOE, calcium hydroxide (Pulpdent ),
Kri Paste or a mixture of Ledermix Paste /ZOE. These may be placed in the canals with
files or a lentulo-spiral. The pulp chamber is then filled with a reinforced ZOE and then
restored appropriately.

Definitions
Nil

Revision date

Policy owner

November 2012

Clinical Leadership Council

Approved by

Date approved

Director of Clinical Leadership, Education


and Research

November 2009

References and related documents

Berger JE. A review of the erroneously labelled mummificationtechnique of pulp


therapy. Oral Surg Oral Med Oral Pathol 1972 34 (1): 131-144

Braham R and Morris M :Textbook of Pediatric Dentistry Williams and Wilkins


980 pp239

Brothwell DJ Guidelines on use of Space Maintainers following premature loss of


primary teeth Can Dent J 63(10): 753 66, 1997

Cameron AC and Widmer RP Handbook of Pediatric Dentistry Mosby-Wolfe 2003

Flaitz CM, Barr ES, Hicks MJ Radiographic Evaluation of pulpal therapy for primary
anterior teeth ASDCJ J Dent Child 56:182-85, 1989

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Fuks AB, Eidelman E. Pulp therapy in the primary dentition. Curr Opin Dent 1991
Oct: 1 (5): 556-63

Holan G, Fuks AB A comparison of pulpectomies using ZOE and KRI paste in


primary molars: a retrospective study Pediatric Dentistry: November/December
1993; 15(6), 403-7

Ibricevic H, Al-Jame Q. Ferric Sulphate and formocresol in pulpotomy of primary


molars: Long term follow up study. European Journal of Paediatric Dentistry 2003
1:28-31

Judd PL, Kennedy DH. Formocresol concerns. A review. J Can Dent Assoc 1987 53
(5): 401-4

Koch G, Modeer T, Poulsen S, Rasmussen P Pedodontics a clinical approach


Munksgaard 1991

Levin LG. Pulpal Regeneration. Pract periodontics Aesth 1998 10 (5):621-4

Lewis B. Formaldehyde in Dentistry. Clin Pediatr Dent 1998 22(2): 167-77

Llewelyn DR UK National Clinical Guidelines in Paediatric Dentistry The pulp


treatment of the primary dentition Int J Paed Dent 40: 248 52: 2000

Myers DR, Shoaf HK, Dirksen TR, Pashley DH, Whitford GM, Reynolds KH.
Distribution of 14C- formaldehyde after pulpotomy with formocresol. J. Am Dent
Assoc 1978 96 (5): 805-13.

Papagiannoulis L. Clinical studies on ferric sulphate as a pulpotomy medicament in


primary teeth. European Journal of Paediatric Dentistry 2002 3: 126-132

Pruhs RJ, Olsen GA, Sharma PS. Relationship between formocresol pulpotomies on
primary teeth and enamel defects on their permanent successors. J. Am Dent. Assoc
1977 94(4): 698-700

Rolling I, Lambjerg-Hansen H. Pulp condition of successfully formocresol treating of


primary molars. Scand J Dent Rec 1978 86: 267-272

Clinical Pediatric Protocols Journal of Clinical Pediatric dentistry 3rd Edition 1995,
pp 32

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