Pulp Therapy in Pediatric

• Why ?
Pulp Therapy in Pediatrics
• When ?
Primary and Young Permanent Teeth
• How ?
Robert J. Feigal, DDS, PhD
Professor
Pediatric Dentistry

Kids come in a variety of sizes and they

Kids are Great Patients
arrive with a range of disease

Some appear fine --

Most show little decay and are at
generally low caries risk

Nice Kid -- Check His Smile

1
 But on closer examination are in real trouble
A few are in REAL TROUBLE

This is a Serious Bacteriological Infection

Complete with Systemic Effects

4 Year Old Patient

While others find trouble that is not disease

Non-restorable molars

Draining
abscesses

Complete pulpal necrosis of primary molars and periapical infection

Traumatic Injury Directly Involving the Pulp Tissue

Why Pulp Therapy ?

• Pulp tissue is alive and functioning
– Surrounded by the hard
structures of teeth
– It, in fact, has produced much
of that very hard structure
– It can produce more hard
structure as a defense system -
part of inflammatory response
– It provides nutrients and
innervation to the pulpal-dentin
complex
Traumatic Injury Directly Involving Pulp Tissue

2
 Early Dentin and Enamel

Odontoblasts and Ameloblasts

Hard at work
Secreting pre-enamel and
pre-dentin matrices

A Pulp Under Severe Stress Why Pulp Therapy ?

• Pulp tissue is alive and
functioning
– Pulp has the potential to produce
Pulpal cell a robust inflammatory response to
irritation / infection
response --
– By its inflammatory responses, it
also produces pain for the patient
Inflammatory cells – Pulp tissue can break down and
become necrotic
Odontoblasts – Infection / inflammation can
producing more spread throughout the pulp tissue
and out the tooth to the
dentin surrounding tissues

First permanent molar

Why Pulp Therapy ?
with deep caries and • Pulp tissue is alive and functioning
incomplete root
formation
– Therefore, the pulp tissue requires careful
protection in all that we do in dentistry to
avoid the negative responses and to
encourage the positive ones.

– This affects diagnostic decisions,

Same tooth restorative decisions, prep designs,
18 months later -- methods of preparation, materials used.
reparative dentin
and complete roots

3
 Levels of Pulp Therapy
in Primary Teeth The Range of Pulp Therapy
1990
1. Indirect Pulp Capping
2. Direct Pulp Capping
3. Vital Pulpotomy
4. Pulpectomy
1. Rarely suggested for primary teeth
2. ZOE fill

The Range of Pulp Therapy Levels of Pulp Therapy

2000 in Primary Teeth

The level of
• Indirect Pulp Therapy
therapy depends
• Direct Pulp Capping
upon the level of
• Partial Pulpotomy - Cvek Pulpotomy
injury or disease,
• Pulpotomy
• Pulpectomy Therefore, careful
– Commonly suggested in primary teeth diagnosis is vital
– Ca(OH)2 fill or Iodoform-Ca(OH)2 mixes

Pulp: A Continuum of Care driven by Symptoms

Diagnosis, then Therapy
Pathology
• What do signs and symptoms tell us ?
• What influences your diagnoses ? Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.

• How precise can you be ? (Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
• What does it matter anyway ? (Xray) (Fistu.)
Symptoms
• Often in Endodontic thinking, it is an
Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
all-or-nothing decision,
Treatment
i.e. Pulpal inflammation, yes RCT Restore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext
• In Pediatrics this is a more subtle choice

4
 Caries in dentin does affect pulp
A Continuum of Care driven by Symptoms

Enamel
Pathology

Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis

- PA involv.
Early inflam
response
M/O in Dentin
Dentin

Pulp

Clinical presentation
Caries Size, Shape, and Proximity

Inter-radicular and
Periapical Boney Changes

After caries removal

and pulp chamber
opening
Radiographic Signs of Caries Into the Pulp and Necrosis

A Continuum of Care driven by Symptoms A Continuum of Care driven by Symptoms

Pathology Pathology

Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv. Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.

(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)

(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
(Xray) (Fistu.)
(Xray) (Fistu.)
Symptoms
Symptoms
Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
Treatment
Restore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext

5
 Deep Caries Into the Pulp Deep caries without Pulpal Exposure

A Continuum of Care driven by Symptoms A Continuum of Care driven by Symptoms

Pathology Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv. Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.

(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.) (Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)
(Xray) (Fistu.) (Xray) (Fistu.)
Symptoms Symptoms

Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
Treatment Treatment
Restore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext Restore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext

Levels of Pulp Therapy

A Continuum of Care driven by Symptoms
in Primary Teeth
Pathology
The level of
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv. therapy depends
(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.) upon the level of
(Xray) (Fistu.) injury or disease,
Symptoms
Therefore, careful
Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp diagnosis is vital
Treatment
Restore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext

6
 Pulpal Diagnosis
• How does this work with children ?
• Different communication skills
• Need for parental input
• Questionable use of objective tests
Pulpal Diagnosis
• Reports of Pain
– Is it spontaneous ?
– Or
– Is it pain that is stimulated ?
• Question to parents:
– Does your child wake up from sleep
because of tooth pain
Pulpal Diagnosis
• Reports of Pain
–Is it spontaneous ?
–Or
–Is it pain that is stimulated ?
• Question to parents:
–How long has this been going on?
Methods of Pulp Diagnosis
in Children
• Clinical signs
• Patient reported symptoms
• Radiographic signs
• Hot / Cold stimulation **
• Electronic pulp testing **
Why the Pain Questions ?
• Early in the caries process, eating sweets
or chewing on food can cause pain
– This tooth may well be treated by restoration
without involving entering the pulp
• But only late in the process, when the pulp
is irreversibly involved does one find
spontaneous pain.
– At this point, entering the pulp and correct
therapy of the tissue is necessary
Pulpal Diagnosis
• Clinical observations
–Hard tissue signs
–Soft tissue signs
–Physical manipulations
• Mobility
• Pain to percussion
7
 4 Year Old Patient
Pulpal Diagnosis
• Radiographic diagnosis
Non-restorable molars
–Extent of caries
• Depth
Draining • Shape
abscesses
• Proximity to pulp
–Boney changes
• Inter-radicular radiolucency
• Peri-apical radiolucency
–Pulp shape changes
Complete pulpal necrosis of primary molars and periapical infection
–PDL signs

Radiographic Signs Radiographic Signs

Abscessed tooth
Deep dentin
caries

Dentin PA infection
caries
Enamel
caries

Radiographic Signs A Continuum of Care driven by Symptoms

Pathology
Health - Irritation - Acute Infl.- Infection - Chronic Infl.- Necrosis - PA involv.

(Occas. pain on stim.) --- (Spont. Pain) -- (Percussion sens.) -- (Mobil.)

(Xray) (Fistu.)
Internal
resorption Symptoms
Inter-radicular Irritation -- Isolate Pulp (seal) ---- Remove some pulp -- Remove all pulp
radiolucency
Treatment
Restore ---- IPT ------ Pulpotomy --------- Pulpectomy --- Ext

8
 Indirect Pulp Therapy
Pulp Tissue Biology Evolution of a Method
• New concept of leaving some caries
(1960s) Minimal, hard caries left behind plus
behind, in order to stay out of pulp and re-entry for full removal
allow a normal healing process.

1. Indirect Pulp Therapy (1980s) Minimal caries left behind and

A new take on an old treatment no re-entry

2. Atraumatic Caries Treatment (ART)

3. “Sealing in” early dental caries (1990s) Major caries left behind

IPT: Evolution of a Method Indirect Pulp Therapy

Early Literature:
Massler, 1955 J Tenn D A 35: 399
King, 1965 Oral Surg 20: 633
Aponte, 1966 J Dent Child 33: 164
Frankl, 1972 Oral Surg 34: 293
Sawusch, 1982 J.A.D.A. 104: 459
Newer Literature:
Fuks, 1991 Curr Op Dent 1: 556
Bjorndal, 1997 Caries Res 31: 411
Leksell, 1996 End Dent Tr 12: 192
Farooq, 2000 Pediatr Dent 22: 278
Al-Zayer/ Krusky, 2001 UMich Theses
Weesheijm 1999 Caries Res 33: 130 Deep Caries, Remove Infected Dentin, Evidence of Healing
Falster, 2002 Pediatr Dent 24: 241 but No Symptoms Leave Affected Dentin i.e. Dentin Formation
Vig et.al 2004 Pediatr Dent 26:214 of Pulp Pathology or Root end Closure
Related Literature:
ART 1990-2004
Mertz-Fairhurst 1998 J.A.D.A. 129: 55

Indirect Pulp Therapy Indirect Pulp Therapy

• Procedural Steps
• Indications
– Tooth with gross caries but no spontaneous pain
symptoms
– No evidence of PA or IR pathology on radiograph
– Restorable tooth
– Healthy child -- no immune system compromise
– Careful diagnostic procedures
– Profound anesthesia
– Rubber dam isolation
– Removal of infected dentin - stop before
entering pulp
– Critical cleaning of enamel-dentin junction
– Placement of calcium hydroxide at deepest
– Seal the dentin with GIC base material
– Restore with a material that seals margins

9
2001 - Over 90% success in primary and permanent teeth.

10
 First permanent molar
with deep caries and
incomplete root
formation

Same tooth
18 months later --
reparative dentin
and complete roots

11
 Direct Pulp Capping
• Indications
– A clean, small exposure of the pulp
– Exposure shows no signs of inflammation
– No symptoms of pain
– Healthy tooth
– Healthy patient

Direct Pulp Capping

• Procedural Steps
– Careful diagnoses
– Profound anesthesia
– Isolation
– Gently rinse the exposure site
– Cover the exposed pulp with calcium
hydroxide or MTA
– Place a bonding base on the surrounding
dentin
– Restore the tooth

Partial Pulpotomy Partial Pulpotomy

• Procedural Steps
• Indications
– A small and clean exposure of pulp
– Ideally, a traumatic fracture causing the
exposure
– No previous signs or symptoms of pathology
– Healthy patient without immune system
compromise
– Careful diagnoses
– Profound anesthesia
– Isolation
– Use a small, clean round bur to remove about 2 mm
of pulp tissue at the exposure site
– Hemostasis by most gentle means, saline or LA rinse
is best
– Placement of a layer of calcium hydroxide or MTA
– Bonded base over the remaining dentin
– Protection with bonded composite resin
– Restore the tooth to full esthetics and function

12
 Cvek Partial Pulpotomy
• Perfect for Trauma Cases
• Excellent Long Term Success
• Local area pulpotomy with Calcium
Hydroxide
• Success even with hours and days of
exposure !

Anterior trauma

13
 Ellis Class III fractures

Isolated and ready for care Partial Pulpectomy

A clean and careful entry into the pulp Gentle hemostasis with sterile saline or
horn -- about 2 mm. LA solution

14
Gentle placement of calcium hydroxide onto
the pulp
Protection of remaining dentin

Etching for the esthetic restoration Bonding agent placement

Early composite resin coverage Completed composite resin coverage

15
 Radiographic follow-up
Major reasons to use the
partial pulpotomy method
• It recognizes the limited inflammatory
reaction to the pulp in some clinical
circumstances
• It recognizes the healing potential of the
pulp when challenged in a limited way
• It allows the best chance for pulpal
maturity, completion of dentin formation,
and root end closure -- leading to
long-term root and crown strength

Pulpotomy
• Indications
– Tooth with symptoms of deep decay and
short-term spontaneous pain
– No pain to percussion
– No radiographic signs of PA or IR pathology
– Restorable tooth
– Patient with compliant behavior
– Healthy patient -- no immune system
compromise

Second primary molar with deep caries, symptoms,

Pulp Exposure During Prep but no signs of full pulpal necrosis or PA pathology

16
Second primary molar -- 4 years post pulpotomy Post pulpotomy -- normal time of resorption

Hard Tissue Signs

After Initial Preparation

Access Opening and Tissue Seating the SSC Crowns

Removal over Pulpotomy

17
 Pulpotomy
Final Restorations • Procedural Steps
– Careful diagnostic work-up
– Profound anesthesia
– Rubber dam isolation
– Tooth prep for restoration
– Caries removal
– Surgically remove the roof of the pulp chamber
– Pulp removal with slow speed large round bur
– Hemostasis at pulp stumps at root orifice
– Placement of medication on blotted dry cotton (4 min)
– Check for fixation and any further bleeding
– ZOE base on fixed tissue
– SSC restoration

Improper Pulpotomy

Pulpectomy
• Indications
– Tooth with signs of pulpal necrosis and ongoing
pain symptoms
– Radiographic evidence of PA and/or IR pathology
– Restorable tooth
– Tooth with value -- esthetic, function, space, growth
– Healthy patient -- no immune system compromise

18
 Newest Data Published Pulpectomy
Vig, Coll, Shelton, and Farooq (Univ Maryland) • What is the traditional stance on
Caries Control and Other Variables Associated with pulpectomy?
Success of Primary Molar Vital Pulp Therapy.
Pediatr Dent 26: 214-220, 2004
Success • What has changed?
Overall Primary 1st Primary 2nd
FP 70% 61% 83% • What are the newest data?
IPT 94% 92% 98%

Recent Thesis Vitapex Success > ZOE Success

Intern. J Paediatric Dent, 2004
Steven Rayes
Mortazavi and Mesbahi, “Comparison of zinc oxide eugenol and
An Evaluation of Pulpectomies Utilizing Vitapex for root canal treatment of necrotic primary teeth”

Vitapex root canal filling material in Primary

52 teeth, followed up to 16 months
Anteriors and Molars: A Retrospective Study
ZOE Vitapex
December, 2003
Success 78% 100%

Alaska study 85% over 0.5 to 4.9 years

Signif effects of: radiolucency, type of
restoration, and treatment location

Pulpectomy Calcium Hydroxide Paste with Iodoform

• Procedural Steps Antibacterial
– Diagnostics Readily resorbable
– Profound anesthesia
– Rubber dam isolation
– Prep for restoration
– Caries removal
– Access opening into pulp chamber
– Pulp extirpation -- barbed broaches
– Physical cleaning of canals -- files
– Rinsing with sodium hypochlorite solution
– Dry canals
– Inject with calcium hydroxide plus iodoform paste
– Place base over paste DiaDent Vitapex from:
– Restore with full coverage -- SSC DiaDent Group International, Inc 604-451-8851

19
20
 Finish with Full Coverage
• Longevity of SSC is twice that of any
intra-coronal restoration
• Why ?
– Extent of physical damage to the tooth results
in weakness
– Pulpectomy results in tooth structure
dehydration and eventual brittleness
– Need for a complete seal from the oral cavity
– High caries risk patient can benefit from
having the other tooth surfaces covered and
free from recurrent decay

Extraction
• Indications
– Non-restorable tooth
– PA and/or Inter-radicular pathology
– Soft tissue swelling or draining fistula
– Tooth with limited long-term value
– Limited patient compliance

How about Extraction as a Pulp Therapy ?

21
 4 Year Old Patient
A happy patient -- post extraction

Non-restorable molars

Draining
abscesses

Complete pulpal necrosis of primary molars and periapical infection

The pulpal-dental complex

1. Treat it as the ally that

it is.
2. Diagnose carefully
3. Choose therapy according
to guidelines
4. Perform the chosen therapy
with care

22