Department of Pediatric Dentistry, Medical University of Lodz

Pulp diseases in primary and

immature permanent teeth
– symptoms and treatment
Dental pulp characteristics

 Specific anatomical location

 Presence of odontoblasts
 Rich blood supply (branches of alveolar arteries) and high blood flow -
in mature teeth (closed apex) 40-50 ml/min/100g of pulp tissue;
many anastomosis
 Limited lymphatic circulation
 Rich pulp innervation
 Pulp matrix: ground substance composed of proteoglycans and
glycosaminoglycans and fibers ( mainly collagen fibers)
 Changes in pulp built with age – decrease of cell components,
increase of fibers
General information about pulp
- pulp innervation

 Pulp nerves - autonomic (vegetative) sympathetic fibers and also two types sensory fibers of
trigeminal nerve: A and C fibers - enter the pulp through the apical foramen
Sensory fibers:
A fibers (90% A-delta and 10% A beta): myelinated; are mainly localized nearby the dentin ( the highest
density in pulp horns) and are characterized with low threshold and high conduction speed; respond
to mechanical stimuli with acute pain which is easy to localize
C fibers: non- myelinated; localized mainly in central part of dental pulp or in cell-rich area, and are
characterized with higher threshold and slow conductivity, conduct dull ache in response to thermal,
mechanical, and chemical stimuli
Factors detrimental for tooth pulp

Factor Example
Infectious • Bacteria and toxins from caries cavity or periodontal pocket
• Bacterial microleakage
• Exposure of dentinal tubules after mechanical tooth trauma
• Blood vessels (in systemic diseases, for example scarlet fever, sepsis)

Chemical • Dental materials, for example eugenol, acid etchant, hydrogen peroxide, bonding systems,
restorative materials
Mechanical • Acute trauma (luxation, fractures)
• Chronic trauma (bruxism, pathological teeth brushing)
• Orthodontic mistreatment
Thermal • Too hot or too cold food on exposed dentine or deep metal fillings
• Heat generated during cavity preparation (drilling)
• Heat generated during material polymerisation

Ischemia • Blood vessels constriction after local anaesthesia with vasoconstrictors (noradrenaline)

Physical • Antineoplastic radiotherapy

• Galvanic current – metals with different electric potential present in the mouth
Pathogenesis of pulp diseases

Diseases that increase risk of pulp inflammation:

 enamel hypoplasia,
 dental invagination (Invaginated tooth/ Dens invaginatus )
 general diseases
-sickle cell anemia (lowered blood flow, blocking of blood vessels with adhesive red cells)
-hypophosphatemia (large pulp chamber, prominent pulp horns, thin layer of mineralized
tissue)
 Pathogenesis of pulp diseases in milk teeth

Pulp of milk teeth is characterized by morphological variability in subsequent developmental stadia

e.g root development, root formation, root resorption
Before resorption of the root starts, the pulp is characterized by:
 good pulpal vascularity
 high cellular component and less number of fibers
 lack of subodontic (subodontoblastic) plexus and sensory fibers in dentinal tubules (less response
during cavity preparation)
 complicated morphology of roots and radicular pulp – anastomosis between root canals,
accessory canals
 fast spreading of inflammatory process and early involvement of periapical tissue
 Dental pulp of milk teeth

Factors connected with morphology of milk teeth that make milk teeth more prone to pulp
inflammation
 thin layer of enamel and dentin
 low mineralization of enamel and dentin
 a straight course of dentinal tubules.
Factors mentioned above are responsible for: acute course of caries in milk teeth (lack or thin layer of
sclerotic and reactionary), higher risk of pulp exposure and increased permeability of mineralized
tissue for the pathological stimuli.
 Symptoms and treatment methods for pulp
diseases of primary dentition

Inflammation Reversible Partial irreversible Irreversible complete

Symptoms I degree II degree III degree

Spontaneous pain no no/yes no/yes

Pulp exposure (carious) no yes yes

Pulp reaction for stimuli yes yes no

Pulpal bleeding no * yes (moderate/mild , light red no/yes (strong, dark red blood
blood colour) colour)

Percussion tenderness no no/yes no/yes

Treatment Indirect pulp Pulp amputation (pulpotomy) pulpectomy/tooth extraction

capping
 Pulp polyp

Chronic Hyperplastic pulpits (chronic proliferative pulpits/ pulp polyp)

– is a type of irreversible chronic pulpits
-the widely exposed pulp of primary teeth or pulp of open apex permanent
teeth may respond with growth of granulomatous tissue, covered with
epithelium
Usually is not painful due to lack of sensory fibers in superficial layer of the
polyp, bleeds on probing or when traumatized
Treatment of pulp diseases in primary teeth regarding
pulp status during treatment

Vital methods – procedure preserve pulp vitality

a) Biological – in order to preserve vital pulp tissue (whole pulp or its part) with normal
functions:
 Indirect pulp capping
 Direct pulp capping
 Partial or complete pulp amputation with the use of MTA or calcium hydroxide
b) Non biological – in order to preserve vital pulp only in canals but pulp functions are
weakened :
 Amputation with formocresol or ferric sulfate

Mortal methods – when the pulp is completely non vital.

 Local factors that stand for endodontic
treatment (pulp treatment) of primary teeth

 Reversible or irreversible pulp inflammation

 Crown part of the tooth is preserved, allowing for the tooth reconstruction
 No permanent successor germ present in the bone
 Maximum three molar teeth with deep caries lesions requiring pulp therapy
 Primary teeth crowding
 To avoid mesial drift of first permanent molars during eruption, when there is
no second primary molar present
 Local contraindications for endodontic
treatment of primary teeth
 Gross damage of tooth crown, impossible to restore
 Non functional tooth, when permanent tooth germ is present
 Tooth with caries lesion penetrating through chamber floor
 Tooth with physiological resorption (less than 2/3 of root present)
 Tooth with pathological root resorption
 Chronic periapical inflammatory changes with fistula purulenta or bone loss
 More than 3 molar teeth in need of pulp treatment and large caries lesions
 Serious oral hygiene neglect
 Considerable swelling
 Orthodontic indication
Systemic factors that stand for endodontic treatment
of primary teeth

 Good cooperation with a patient that allows us to introduce the endodontic

treatment
 Regular check up visits
 Systemic diseases with high risk of complications during tooth extraction
 hemophilia and other coagulation disorders
 diabetes, when there are contraindications for general anaesthesia

 If general anaesthesia is necessary for tooth removal, for example chosen heart defects,
mucoviscidosis, muscle dystrophy
 Congenital angioedema
Systemic contraindications for endodontic
treatment of primary dentition

 Uncooperative child patient and no regular check up visits

 Patients with high risk of bacteriemia complications:
 Congenital heart defects (risk of bacterial endocarditis)

 Lowered immunological defense

 Carcinoma (oncologic patients)
 Before organ transplantation
 Systemic contraindications for endodontic
treatment of primary dentition

 Immunocompromised patients
e.g. HIV infection, T-cells immunodefficiences (SCIDS), neutropenia, sickle cell anemia,
chemotherapy, bone marrow transplantation or organ transplantation (vascular organs: liver ,
kidney, heart) ,Graft versus host disease, biphosphonate therapy, radiotherapy in head
region, poorly controlled diabetes, patients after splenectomy or with asplenia, long-term
treatment with glicosteroides, autoimmunological diseases (e.g. systemic lupus
erythematosus, juvenile idiopathic arthritis)
 Patient with high risk of infective endocarditis
- Prosthetic valve replacement
- Previous history of infective endocarditis
-congenital heart disease e.g. unrepaired cyanotic shunts, repaired with residual shunt or
completely repaired CHD with prosthetic material for at least 6 months after procedure
Methods of pulp treatment in milk teeth

Indirect pulp capping

Direct pulp capping
Pulpotomy (complete/coronal)
 Indirect pulp capping
indications and contraindications

Examination Evaluation criteria Indications Contraindications

Anamnesis Provoked pain Yes/no -
Spontaneous pain no yes
Clinical Deep cavity yes Destruction of tooth crown
examination making it impossible to restore

Pulp exposure diameter No pulp exposure or possibly yes

pulp visible through dentine
Pulp reaction to stimulus Normal Abnormal

Swelling, fistula no yes

Percussion reaction no yes
Additional Pathological changes no yes
tests visible on radiograph
Source: Wspó
Współczesna stomatologia wieku rozwojowego wyd. 1, 2017
 Indirect pulp capping

Step-wise excavation –two step indirect pulp capping

one step indirect pulp capping
Indicated in case of deep caries lesion with demineralization seen on x-ray
involving 75% of dentin
Cavity is dressed temporarily with :
zinc oxide – eugenol for 2-3 months
or glass-ionomer cement (6 months)
On second visit the remaining caries can be excavated without
exposing the pulp due to tertiary dentin deposition, and
tooth is permanently restored
ws - filling
cp - liner
ct – ondontotropic material e.g. hard setting
calcium hydroxide
 Medicaments used for pulp treatment in
primary dentition – indirect pulp capping
procedure

Zinc oxide and eugenol IRM Ketac Molar

(Glass-ionomer
cements)
 Direct pulp capping
indications and contraindications

Examination Evaluation criteria Indications Contraindications

Anamnesis Provoked pain yes -
Spontaneous pain no yes
Intraoral Deep cavity yes Destruction of tooth crown
examination making it impossible to rebuild

Pulp exposure diameter Very small ( pinpoint) More than 1 mm

blood colour Light red -

bleeding Not intense Intense bleeding or no
bleeding
Pulp reaction to stimulus Normal abnormal

swelling no yes
Percussion reaction no yes
Additional Pathological changes no yes
tests visible on radiograph
Source: Wspó
Współczesna stomatologia wieku rozwojowego wyd. 1, 2017
 Direct pulp capping

Indications (limited!) Contraidications

• Pinpoint pulp exposure during cavity • Profuse bleeding from the pulp exposure
preparation • Spontaneous pain
• Small traumatic pulp exposure in immature • Pain at night
milk tooth < 24hours • Swelling
• Sinus tract (fistula)- symptom of chronic periapical inflammation
• Pathological root resorption (RTG)
• Radicular pathology (RTG)
• Unrestorable teeth (damage of crown, perforation of the
floor of pulp chamber)

 Indications
Indications for direct pulp capping in milk teeth are limited!
 Direct pulp capping of carious pulp exposure in primary teeth has poor prognosis and is generally not recommended
 Medicaments used for direct pulp capping in
primary dentition

Material used directly on pulp exposure to stimulate tertiary dentin formation (dentinal bridge):
-calcium hydroxide non-setting (+ hard setting)
-or MTA

Biopulp Chema
Pro Root MTA Dentsply
Calcium hydroxide non-setting paste
 Pulpotomy
indications and contraindications

Examination Evaluation criteria Indications Contraindications

Anamnesis Provoked pain yes no
Spontaneous pain Yes/no Long lasting

Intraoral Deep cavity yes Destruction of tooth crown

examination making it impossible to rebuild

Pulp exposure diameter Small or large -

blood colour Light red -

bleeding Not intense Intense bleeding or inflammatory
exudation
Pulp reaction to stimulus Normal/abnormal Necrosis of pulp in root canals

swelling no yes

Additional Pathological changes no yes

tests visible on radiograph
Source: Wspó
Współczesna stomatologia wieku rozwojowego wyd. 1, 2017
 Pulpotomy

Indications Contraindications

• Traumatic pulp exposure > 24 h Profund bleeding or excudation from pulp stamps
• Carious pulp exposure Necrotic pulp
• Asymptomatic pulp, or minimal history of Unrestorable teeth
pain Radiographic findings : patological root resorption/
• Absence of inter-radicular / periapical bifurcation radiolucency
pathology Advanced physiological resorption
Systemic diseases with high risk of bacteriemia
complications
 Medicaments used for amputation
treatment of pulp in primary teeth

formocresol Astringedent (ferric sulfate) Pro Root MTA

 Medicaments used for amputation
treatment of pulp in primary teeth

Calcium hydroxide paste is not recommended as therapeutic agent in

pulpotomy in milk teeth due to increased risk of internal resorption.
 Milk teeth are more prone to pathological pulp resorption, which is
observed after use of calcium hydroxide on pulp stumps ( the risk of
resorption increase with the degree of pulp inflammation)
 Pulpotomy under local anaesthesia (vital)

Administer local anaesthesia, isolate the tooth (rubber dam) and start pulpotomy procedure:

Remove dental caries and indentify site of pulp exposure and get access to the pulp chamber

Change bur to sterile, remove the roof of the pulp chamber

Remove coronal pulp with bur or sharp excavator

use sterile moist cotton pledget (e.g. sterile isotonic saline) to achieve haemostasis (bright red blood should be seen at
amputation site, haemostasis < 3-4 minutes); prolonged bleeding from residual pulp, that cannot be stopped with with moist
cotton pledget within 3-3-4 min,
min, indicates for irreversible pulpitis-
pulpitis- pulp extripation is needed!

Apply therapeutic agent to the radicular pulp - chose one of options:

-MTA (about 2 mm layer)

-15,5-20% Ferric sulphate- 15 second application and then application ZOE paste

-procedure with the use of Formocresol

Apply liner and place coronal restoration ( for class II by Black use matrix band) or restore with stainless steel crown
 Formocresol Pulpotomy in primary molar teeth

Administer local anaesthesia,

anaesthesia, isolate the tooth (rubber dam) and start pulpotomy procedure:
procedure:
 Remove dental caries and indentify site of pulp exposure and get access to the pulp chamber
 Change bur to sterile and remove the roof of the pulp chamber
 Remove coronal pulp with bur or sharp excavator
 Wash with saline and dry the pulp chamber
 Apply Formocresol to the radicular pulp on a cotton plellet (cotton plellet moistened with formocresol should be
left for 5 min.) or is some cases for for 5-7 days
 Apply zinc oxide - eugenol and formocresol paste on root canal openings and the bottom of pulp chamber (3-4
mm layer)
 Apply liner (e.g. carboxyfine cement) and place coronal restoration ( for class II by Black use matrix band) or
restore with stainless steel crown
Formocresol pulpotomy

 Formocresol pulpotomy can be introduced in exeptional cases after pulp

devitalisation (2 or 3 –steps pulpotomy) In pulpotomy after devitalization
on second visit cotton pledget moistened with formocresol is left for 5
minutes in pulp chamber or for 5-7 days (3 visit pulpotomy procedure) in
case of minimal pulp reactivity or some doubt about pulp disinfection
 There is higher risk of periapical inflammation occurrence comparing to
vital pulpotomy
 Pulp extirpation (pulpectomy)
indications and contraindications
Examination Evaluation criteria Indications Contraindications
Anamnesis Provoked pain yes no

Spontaneous pain yes no

Clinical Deep cavity yes Destruction of tooth crown making

examination it impossible to rebuild

Pulp exposure diameter Small or large -

blood colour Light red or dark red -

bleeding More intense or no bleeding -

Pulp reaction to stimulus abnormal normal

swelling no yes

Percussion reaction no/yes -

Additional Pathological changes no yes

examination visible on radiograph
 Physiological resorption of primary teeth should be taken into
consideration when pulpotomy is considered

Physiological
root resorption of milk teeth starts 2-4 years prior to eruption of
permanent successors.

Resorption of anterior teeth occurs in apical region (on the lingual/ palatal surface)
Resorption of primary molars occurs in interradicular region ( in bifurcation and on internal surface of the roots)
Resorption it is a long-term process in which the periods of active resorption can be interrupted by the periods of
apposition of reparative cementum and attachment peridontal ligaments ;
Primary roots undergo physiological resorption in sinus and linear form.
 Pulpectomy – milk teeth

 Treatment of Complete irreversible pulpitis or pulp necrosis

Pulpectomy or extraction if RCT is impossible e.g. due to child attitude to dental treatment, general
disease with immunodeficiency or risk of bacterial endocarditis or due to local factors
Pulpectomy can be considered:
- in children in good general health condition
- tooth should be restorable, its retention is required, roots morphology allows for RTC and there
are intact non-resorbed root/s or initial root resorption phase (resorption of incisors starts on the
lingual/ palatal surface of apical region and is therefore not visible on x-ray )

Pulpectomy in deciduous can be introduced:

In Incisors in children up to 4.5 years
In Canines in children up to 7-8 years
In Second molars before eruption of first permanent molars
Each tooth in case of absence of permanent successor, tooth located next to cleft palate, milk tooth in a child with
haemofilia
 Pulpectomy - milk teeth

Recommended are:
 radiological assessment of the development phase and root shape, as well as radiological determining of the
length of canals on X-ray (working length at least 2 mm shorter than radiological one)
 Cavity should be opened widely to get access to pulp chamber ( milk teeth have large pulp chambers)
 Removal of the roof of the pulp chamber and entire coronal pulp should be done fallowed by cautious chemo-
mechanical preparation of canals (1-2,5 %NaOCl, 0,2 -0,4% CHX, 6% Citric acid, 0,9% NaCl), files max. Number 30-
35
 Root oburation with resorbable paste on the same visit or placing a cotton wool pledget with disinfectant solution
(formocresol) in pup chamber and seal the cavity with a temporary material for 7-10 days ( especially if there is
exudation) and than obturation root canals with resorbable paste(Zinc- oxide eugenol cement,Calcium hydroxide
paste, Iodoform paste )
 Pulpectomy- procedure steps in milk teeth

 Pain control (local anaesthesia is needed in cases of vital irreversibly inflamed pulp)
 Isolation (rubber- dam is indicated)
 Complete removal of caries
 Removal of the roof of the pulp chamber and entire coronal pulp, washing with saline and pulp assessment ( if pulp is
bleeding – one step procedure possible, if is necrotic two step procedure recommended)
 Radicular pulp removal and root canal irrigation
 Measurement of the length of canals on X-ray (working length about 2 mm shorter than radiological one) Chemo-
mechanical preparation of canals (1-2,5% NaOCl, 0,2 -0,4% CHX, 6% Citric acid, 0,9 % NaCl), files max. number 30-35,
drying with paper cones
 Root oburation with resorbable paste
-on the same visit
-or placing a cotton wool pledget with disinfectant solution (formocresol) in pup chamber and seal the cavity with a
temporary material for 7-10 days (especially if there is exudation) and than obturation root canals with resorbable
paste
 Control X-ray and permanent tooth restoring
 Clinical and radiological check-ups
 Pulpectomy – milk teeth

esorbable materials used for canal obturation in primary teeth:

Zinc- oxide eugenol cement (ZnO/E)
Calcium hydroxide paste
Calcium hydroxide paste with iodoform
Iodoform paste
aterials used for root cannal filling in milk teeth should:
be resorbable
have antibacterial properties
easily flow into the root canal
not be irritating to or cause inflammatory reaction of permanent tooth germs
should contain contrast agents ( be visible on X-ray)
 Medicaments used for root canals
filling in primary teeth
- resorbable paste!

Zinc oxide and eugenol Calcium hydroxide paste Calcium

hydroxide+iodofo
paste
or iodoform past
Pulp diseases in immature permanent teeth
Eruption dates and root completion of maxillary permanent teeth acc. to Avery.

Tooth 1 2 3 4 5 6 7 8

Eruption
years 7-8 8-10 11-13 10-12 10-12 6-7 11-13 17-20

Root
complete 9-10 12-13 14-15 12-14 13-14 9-10 14-15 18-25
years

Source: Wspó
Współczesna stomatologia wieku rozwojowego wyd. 1,
1
 Eruption dates and root completion of mandibular permanent teeth according to Avery.

Tooth 1 2 3 4 5 6 7 8

Eruption
years 6-7 7-8 8-10 10-12 11-13 6-7 11-13 17-20
Root complete
years 9 10-11 12-14 12-14 14-15 9-10 14-15 18-25
 Root development
Ketterl stages of root development
 Stage of divergent walls-( within first year after
eruption) thin walls root canal short, and wide with
the highest diameter in apical part
 Stage of parallel walls (about 18 months after the
tooth eruption)- walls are thicker and longer, root
canal narrows

 Stage of convergent walls (2-4 years after

eruption)- root length is completed; forming of
apex and apical foramen take place
 Complete root formation- apposition of
cementum in root canal forming of apical
constriction

Roots are completed after eruption by 1-1.5 years for deciduous teeth and by about 3 years after eruption for permanent
teeth Hertwig's epithelial root sheath --determines root length and outline and number of root canals of tooth
Growth of the Hertwig's epithelial root - sheath results in root growth
Characteristics of immature permanent teeth

 large pulp chamber

 more prominent pulp
horns
 wide root canal
 thin root canal walls
 open apex
Dental pulp of immature permanent teeth

 excellent pulpal vascularity (wide open root apex)and better pulp hydration
 higher cellular component and less number of fibers
 high activity of cylindrical shaped odontoblasts
 layer of Weil is rarely present
 lower response to stimuli due to immaturity of nervous tissue (Raschkov’s plexus is formed after the
root completion, there are numerous C fibers and less A fibers then in mature teeth)
 Hertwig's Epithelial Root Sheath ( which has regenerative properties and play important role in root
grown and maturation) is present in apical region of immature teeth

Thinner layer of dentin, with more interglobular space than in mature permanent teethand wider dentine tubules increase the
permeability of dentine to patological stimuli (bacteria, chemical stimuli ect.) = increased t risk of pulp diseases

On the other hand:

Immature teeth have better defensive/reparative properties as the open apex is associated with excellent pulpal vascularity and increases
the chance for a favourable healing response of the pulp
 Pulp diseases classification according to American Ednodontic Society and
American Paedodontic Academy symptoms allowing for diagnosis of pulp
disease

Pulp status

Reversible pulpitis Irreversible pulpitis Necrosis

Clinical course Most often acute Acute or chronic -

Tooth crown colour Normal Normal Normal or grey, less

translucency, loss of shine
Pain Provoked (differentential no - asymptomatic no - asymptomatic
diagnosis with dentine yes - symptomatic: yes - symptomatic:
hypersensivity) Acute or dull, sometimes reaction for
– acute, short pain, gone spontaneous or provoked, heat, pain when biting,
after few seconds when persistent even when feeling of tooth
stimulus is removed stimulus is removed. „protruding” from alveolus
Sometimes difficult to
localize.
Bleeding from pulp no often no

Source: Wspó
Współczesna stomatologia wieku rozwojowego wyd. 1, 2017
 Pulp status

Reversible pulpitis Irreversible pulpitis necrosis

Percussion no no / yes when periapical no / yes when periapical
tissues are inflamed inflammation
Reaction to cold More intense reaction to More intense and no
stimulus cold, pain stops prolonged reaction
immediately after stimulus
is gone
Electric stimulus- reaction Often with lower current With lower current no
(EPT is not recommended for milk intensity intensity
and immature permanent teeth!)
Swelling no Possible if periodontal Possible if periodontal
tissue are inflamed tissue are inflamed

Fistula no no Possible if periodotal

tissue are inflamed
Radiological changes No/ if yes, deep caries no/yes:
cavity or large filling is – visible reason – deep caries cavity, large filling, pulp
visible exposure, trauma, tooth luxation
– when periapical tissues inflammation is present –
radiolucency near furcation or root apex.

Source: Wspó
Współczesna stomatologia wieku rozwojowego wyd. 1, 2017
 Pulp vitality testing in immature teeth

 Sensory response (response is usually due to stimulation Aδ nerve fibers in healthy

pulp-dentine complex (Aδ fibers are quickly damage with hypoxia), C fibers have
higher threshold and may respond only in irreversibly inflamed pulp (C fibers are
more resistant to hypoxia)
- to cold stimuli - ethyl chloride (-41o C), dichloro – difluoro-methane refrigerant spray
e.g. Endo-Frost DDM (-50o C), endo-ice TFE ( -26o), solidified carbon dioxide= dry ice
(-72 to -78o C),
-to application of heat- heated gutta - percha (65-200o C), hot water (stimulation with
hot stimuli should last maximum 5 sec. due to risk of thermal pulp irritation)
- to electric stimuli (assessment of sense threshold in mature teeth)– electrical pulp
testing T is not recommended for open -apex teeth EPT tends to give unreliable
results (high threshold, immaturity of pulp innervation)
 Laser Doppler Flowmetry (LDF) -non-invasive measurement of pulpal blood flow
velocity
 Acute vs chronic periapical inflammation

symptom Periapical inflammation caused by pulp pathology

acute chronic

spontaneous pain yes – intensity depends on amount of no (present only when exacerbation)
exudation (sometimes the feeling of tooth
being „protruded” or elongated)

Pain when biting yes no/ yes

Submandibular or submental lymph Painful, soft, not movable regarding to Not painful, hard, movable regarding the
nodes base tissue, movable regarding the skin basis and skin (painful when
exacerbation)
Alveolus near causal tooth Swelling, redness of mucousa Fistula purulenta (active or passive),
at root apex region: usually in region root apex

 hard and painful subperiosteal abscess

fluctuant – submucosus abscess

Radiography No changes or widening of periodontium Visible radiolucency of bone tissue (in

primary dentition near furcation)

Source: Współczesna stomatologia wieku rozwojowego wyd. 1, 2017

 Materials used for pulp treatment

 Zinc oxide with eugenol (ZOE)

- indirect pulp capping
 Calcium hydroxide
-indirect and direct pulp capping, pulpotomy, apexification
 Mineral Trioxide Agreggate MTA
-direct pulp capping, pulpotomy, apexification
 Biodentine
- indirect and direct pulp capping, pulpotomy,
apexification

Other materials:
 Hydroxyapatite
 Bioceramic materials based on calcium phosphate
 Tri-calcium phosphate
 Collagen fused with calcium phosphate
 Apexogenesis – physiological process of root formation to
reach genetically programmed length and formation of
apical part of the root into anatomically shaped apex. Pulp
and Hertwig’s epithelial sheath are involved in that process.

Procedures that make apexogenesis possible:

 Indirect pulp capping
 Direct pulp capping
 Cvek’s pulpotomy
 Pulpotomy
 Indirect pulp capping

INDIRECT PULP CAPPING

is defined as the application of medicament over a thin layer of remaining carious dentine, after deep excavation to
avoid pulp exposure.
Indications
• uncomplicated crown fracture (Ellis class II)
• deep carious lesion (near pulp exposure)
• the tooth is asymptomatic, no spontaneous pain, sometimes moderate provoked pain (chemical or thermal stimuli)
quickly resolving
• there is positive reaction to vitality tests
• there is no signs of periapical lesions in radiographic examination
I step INDIRECT PUPLP CAPPING
Residual carious dentine directly overlying to the pulp is intentionally left to prevent carious exposure. This dentin, after
washing the cavity (with chlorhexidine or sodium hypochlorite and saline) and delicate drying is dressed with biological
material e.g. with calcium hydroxide or ZOE + liner is applied, and the tooth is permanently restored
II steps INDIRECT PUPLP CAPPING
Remain carious dentin, after washing the cavity (with chlorhexidine or sodium hypochlorite and saline) is dressed
temporarily with calcium hydroxide lining or ZOE and the whole cavity is temporary filled with glass-ionomer cement or
IRM for 3 to 6 months. On II visit assessment of pulpal status , removal of temporary restoration, cautious removal of
remaining carious dentine, washing the cavity (with chlorhexidine or sodium hypochlorite and saline), drying, liner
application + permanent restoration
 Direct pulp capping

-Pinpoint pulp exposures (<1mm) in area of intact dentin, during

carious cavity preparation– iatrogenic or carious- in tooth with
healthy pulp
-recent small traumatic pulp exposure (<1-2 days)
days

Procedure:
 the tooth should be well isolated (cotton wools, rubber dam), dental
instruments set used during caries removing changed to sterile one
 Pulp assess
asses ment – pink site of pulp exposure, bleeding easy to stop
with sterile cotton pledget, blood light -red
 the blood clot should be removed with moistened with isotonic saline
sterile cotton pledget ( or 1-2% NaOCl, water suspension of Ca(OH)2)
prior to application of pulp capping material (MTA or non setting
calcium hydroxide +hard setting calcium hydroxide or Biodentine)
 the tooth should be permanently restored with glass- ionomer base
and permanent restoration
 Positive results after direct pulp capping in permanent immature teeth

 No clinical complications ( no hypersensitivity or pain)

 Positive pulp reaction to vitality testing
 Continued physiological development of the roots
 Dentine bridge formation ( reparative dentin) seen on X-ray after 4-12 weeks ( usually 2-3
months)
 No pathological changes on x-ray:no signs or resorption ( internal and external), pulp
obliteration, pulp calcification, or periapical radiolucency)
 Pulpotomy

Indications: Contraindications
 carious pulp exposure in tooth with
 Irreversible pulpitis of coronal and
reversible pupitis (asymptomatic tooth
radicular pulp
or minimal history of mild pain)
Traumatic pulp exposure>1-2 days  Significant hypersensivity to cold
from trauma or hot stimuli
 Chronic pain of pulpal orgin
 Tenderness to percussion
The range of pulp removal after trauma
depends on pulp status*:  Radiolucency in periapical area
(Cvek’s pulpotomy (1-3 mm) or in root furcation on X-ray
or complete pulpotomy (whole coronal
pulp is removed)  Pulp obliteration, pupl
calcifications

*excessive bleeding from residual pulp, that cannot be stopped with

with moist
cotton pledget indicates that further excision is needed to reach healthy pulp
Partial (Cvek) pulpotomy in immature permanent teeth

Procedure:
 administer adequate local anaesthesia
 isolate the tooth (rubber dam)
 disinfect the tooth and neighboring teeth
 remove caries (in case of carious pulp exposure)
 use a diamond bur at high speed with isotonic saline or water coolant ( so called
gentle technique) to amputate the pulp in to a depth of 1-3mm (until extensive
bleeding stops what indicates that inflamed portion has been removed);
 use sterile cotton pledget moistened with sterile isotonic saline or 3%H202, 1-2% NaOCl,
water suspension of Ca (OH)2to achieve haemostasis
 apply biological material: calcium hydroxide +hard setting calcium hydroxide lining or
MTA cement/ Biodentine
 apply the thin layer of resin –modified glass-ionomer cement (base)
 Restore the tooth permanently
 take X-ray
 Clinical and radiological follow- up
 Complete Pulpotomy

 administer adequate local anaesthesia

 isolate the tooth (rubber dam)
 disinfect the tooth and neighboring teeth
 remove caries (if it is carious pulp exposure)
 get access to coronal pulp, remove the entire root off the pulp and
amputate the coronal pulp ( low speed- ball bur or sharp excavator )
 use sterile moist cotton pledget (sterile isotonic saline or, 1-2% NaOCl,
water suspension of Ca (OH)2, 3%H2O2) to achieve haemostasis
 apply calcium hydroxide +hard setting calcium hydroxide lining , apply GI
liner and restore the tooth permanently
 or apply Biodentine (setting time 12-20 min) or place MTA cement
against the pulp wound and fill the entire cavity, after setting (4-6 hours)
the tooth can be restored permanently
 take X-ray
 clinical and radiological follow up
 Treatment of immature (open apex) teeth: irrevesible pulpitis or pulp
necrosis with or without periapical inflammation

 Apexification – procedure aiming at stimulation of further root development and apical

foramen formation or only calcified barrier in apical region of immature teeth with open
apexes and pulp necrosis or irreversible inflammation (pulpless teeth)
It can be achieved either by the long term procedure using calcium hydroxide as root
canal temporary dressing to allow formation of hard barrier in apical region ,or by short
term procedure -creating an apical plug of MTA or Biodentine

 Revascularization – endodontic regenerative treatment can be used in case of the

immature tooth with open apex and pulp necrosis.
A combination of triple antibiotic paste (minocycline, ciprofloxacin, metronidazole) and
MTA is used -method under research
It is based on the elimination and the replacement of infected necrotic pulp by a
neoformed (pulpal-periodontal- like ) tissue due to the use of the capacity of stem cell
differentiation a After successful revascularization could allow for root growth for length,
thickening of dentinal walls, and apical closure.
Advantage of this method is thickening of dentinal walls which is never (or in rare cases) observed after
apexification procedure.
 Apexification

 Start chemo-mechanical canal preparation

- endodontic shaping with instruments must be very careful and minimal, because the canal
walls are very thin and apical foramen is very wide
- Irrigants: 1-3% NaOCl ,3%H2O2, 2% chlorhexidine, 17% EDTA,1-50% citric acid ,10% carbamide
dioxide, 0.9%NaCl
 Dress the root canal with non-setting calcium hydroxide paste
 Introduce apexification long term procedure with calcium hydroxide* (calcium hydroxide
dressing is changed usually every 3 months until hard barrier is formed)
 or chose short term procedure – start treatment with calcium hydroxide intra-canal dressing
for 1-4 weeks, than remove Ca(OH)2 and fill the apical part of root canal with MTA or
Biodentine

Radiological examination of immature teeth after root canal therapy should be repeated: after 3, 6, 12 months, and then annually up to root completion,
period of 4 years is indicated
Using MTA as a physical barrier appically in immature teeth
(Andreasen et all 2003)

 After 1-4 weeks calcium hydroxide dressing is removed and the root canal(s) is
irrigated with sodium hypochlorite and isotonic saline (use of chlorhexidine is
contraindicated as it inhibits setting of MTA!)
 Small increments of MTA/water mixture is introduced into the canal and gently
condensed with a plugger. I n very open immature apices spongostan can be
placed in apical region prior to sealing with MTA
 The apical MTA plug should be about 4 mm thick ( the entire canal can be
filled with MTA or the coronal part of the canal can be left to be fill with gutta-
percha and a sealer
 To allow setting of MTA a moistened with sterile water cotton pellet should be
placed in the access cavity for minimum 4-6 hours and cavity should be
sealed with temporary material e.g. glass-ionomer or IRM
 Take X-ray
 At the next visit temporary material and cotton pellet are removed. The canal
is irrigated, dried and conventionally filled ( thermoplastic gutta-percha is
recommended), followed by a bonded coronal composite restoration
When apical part of root canal is sealed with Biodentine ( shorter than MTA setting
time a dozen minutes) root canal treatment can be finished at same visit
 Revascularization
It is based on the elimination and the replacement of infected necrotic pulp by a neoformed (pulpal-
periodontal- like ) tissue due to the use of the capacity of stem cell differentiation a After successful
revascularization could allow for root growth for length, thickening of dentinal walls and and
apical closure.
Advantage of this method is thickening of dentinal walls which is never (or in rare cases) observed
after apexification procedure.
Revascularization is two step procedure (Bahns and Trope 2004).
 Step 1:
- removal of necrotic pulp from root canal and desinfection by irrigation with sodium hypochlorite
usually of higher concentration (20 ml of 5,25% NaOCl) and 0.9% NaCl, Insertion of the triple
antibiotic paste into root canal, Placement of a cotton ball at the root canal entrance; Sealing of
the access cavity with a temporary filling.
Triple Antibiotic Paste (TAP)- minocycline ( may cause tooth discoloration) alternatively amoxicillin can be used,
ciprofloxacin and metronidazole
 Step 2:
- under local anaesthesia without vasoconstrictors: After removal of the triple antibiotic paste using
irrigation an apical bleeding is caused. Blood level must be at the cement-enamel junction MTA is
placed on the formed clot at the entrance to root canal + a wet a cotton ball on MTA layer and
sealing of the cavity with a temporary filling.
 Source:
Współczesna stomatologia wieku rozwojowego, pod red. D. Olczak-Kowalczyk,
J. Szczepańskiej i U. Kaczmarek. Med Tour Press International, Wydanie I, Otwock 2017.
QUESTIONS