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AB
FUNDAMENTAL POINT 1
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Questions toAsk When Obtaining aHistory
Regarding Pain
• Describe the pain. Does it linger or subside after
stimulus is removed? Is the pain spontaneous?
• What are the frequency, severity, duration,
triggering agents of the pain (hard food, hot or
cold food, etc.)?
• What are the symptoms (fever, swelling)?
• What has been the analgesic use?
(Fuks etal. 2005; Fuks and Peretz 2016;
Guelmann 2016)
I. Diagnostic Tools
• Periapical radiograph of the maxillary anterior area
(Figure3.1.2a)
• Right and left bitewing radiographs (Figure3.1.2b,c)
• Periapical radiograph of the maxillary left second
primary molar (Figure3.1.3)
J. Differential Diagnosis
• Not applicable
COMPLEX PULP THERAPY
Figure 3.1.3 Preoperative periapical radiograph of the maxillary
left second primary molar showing a deep carious lesion but
no pathological interradicular lesion.
Diagnosis and/or Problem List
K.
Diagnosis
•
Severe early childhood caries
• Deep carious lesion with interradicular pathological
areas in the right mandibular second and first
primary molars with possible irreversible pulp
involvement
• Deep carious lesions and periapical pathologic bone
resorption on the maxillary central and lateral incisors
• Maxillary right primary second molar and mandibular
left primary second molar with deep carious lesions
with possible reversible pulp involvement but without
signs or symptoms of irreversible pulpitis and no soft
tissue pathology
C
Figure 3.1.2 (A) Preoperative periapical radiograph of the
maxillary central and lateral incisors. Note the coronal
destruction and the pathologic bone resorption mainly around
the roots of the central incisors; (B) preoperative right
bitewing radiograph. Note the extensive carious lesions in the
maxillary first and second primary molars and maxillary
primary canine. Total coronal breakdown and pathological
interradicular lesions can be seen in both mandibular right
primary molars; (C) preoperative left bitewing radiograph. Note
the extensive carious lesions in the maxillary and mandibular
second primary molars and maxillary canine. Total coronal
breakdown and pathological interradicular lesions can be seen
in both maxillary and mandibular first primary molars.
Problem List
• High caries risk due to highly cariogenic diet, poor
oralhygiene with moderate to extensive plaque
accumulation
• Several untreated carious lesions with possible
reversible and/or irreversible pulp involvement
Very poor recall compliance (last dental check‐up was
•
two years ago)
• Young, potentially uncooperative, child with need for
extensive treatment on many teeth
L. Comprehensive Treatment Plan
• Discussion with the mother regarding the importance
of maintaining a second primary molar whenever
possible, particularly prior to the eruption of the first
permanent molar for space maintenance
• Extraction of multiple necrotic nonrestorable teeth
• Pulpectomy maxillary right primary second molar
• Mineral trioxide aggregate (MTA) pulpotomy and
stainless steel crown for the mandibular left primary
second molar
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• Considering that the maxillary left primary second
molar was asymptomatic and amenable to be properly
sealed with a leakage free restoration, a selective
caries removal (indirect pulp treatment [IPT]) technique
was chosen to treat the deep lesion
• Comprehensive treatment of other carious lesions
• Behavioral management considerations
• Space maintenance as needed
• Follow‐up care and caries prevention plan including:
BACKGROUND INFORMATION 1
Caries Removal inDeep Lesions
• There are a variety of strategies to choose from
when managing a deep carious lesion with a vital
pulp and without signs of irreversible pulp inflammation (Ten Cate 2001; Yoshiyama et al. 2002; Ricketts
etal. 2013; Green et al. 2015; Innes etal. 2016;
Schwendicke etal. 2016)
• The decision among these strategies will be guided
by the depth of the lesion and by the dentition,
primary or permanent
• Nonselective removal to hard dentin (complete
excavation or complete caries removal): this
strategy uses the same criteria for carious tissue
removal both peripherally and pulpally, and only
hard dentin is left. This may be considered overly
aggressive treatment (Innes etal. 2016)
• Selective removal to firm dentin (IPT): this strategy
leaves leathery dentin pulpally while the cavity
Postoperative and home care instructions
Diet modification
Consider high fluoride and remineralizing
toothpastes
Recall plan (every three months)
Caries risk re‐evaluation and fluoride varnish application every three months
Follow‐up radiographs after six months
margins are left hard after removal. These are
lesions that radiographically extend to lessthan the
pulpal third or quarter of dentin (Innes etal. 2016).
This is the treatment of choice for both dentitions
in shallow or moderately cavitated dentinal lesions
• Selective removal to soft dentin (IPT): a strategy
recommended for deep cavitated lesions
(radiographically extending into more than the
pulpal third or quarter of dentin). Soft carious tissue
is left over the pulp to avoid exposure and further
injury to the pulp. Peripheral enamel and dentin are
prepared to hard dentin, to allow a tight seal and a
durable restoration. Selective removal to soft
dentin reduces the risk of pulp exposure
significantly when compared with nonselective
removal to hard or selective removal to firm dentin
(Maltz etal. 2012; Schwendicke etal. 2013; Innes
etal. 2016)
BACKGROUND INFORMATION 2
A Protective Base
• Guidelines published by the American Academy of
Pediatric Dentistry (AAPD) recommend placement
of a protective base or liner on the pulpal and axial
walls of a cavity preparation to act as a protective
barrier between the restorative material and the
tooth (AAPD 2018–2019)
• Dentin is permeable and allows the movement of
materials from the oral cavity to the pulp and vice
versa. It was believed for many years that pulp
inflammation was caused by the toxic effects from
dental materials (Stanley 1990). However, there is
sufficient evidence to show that pulpal inflammation
resulting from dental materials is mild and transitory,
80 Clinical Cases inPediatric Dentistry
with adverse reactions primarily occurring as the
result of pulpal invasion by bacteria or their toxins
(Brannstrom 1984; Murray etal. 2001)
• Continued marginal leakage with secondary
recurrent caries is probably the most common
cause of pulp degeneration under restorations. In
deep cavities the dentin covering the pulp is thin,
and the tubules are large in diameter and packed
close together providing a route to the pulp
• The materials most commonly used as cavity sealers
are those that have demonstrated multisubstrate
bonding ability to bond the restorative material to the
tooth. These include resin cements, glass ionomers,
and dentin‐bonding agents (Hilton 2009)
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COMPLEX PULP THERAPY
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ABC
Figure 3.1.4 Cavity preparation. (A) The lateral walls were completely cleaned to hard dentin and soft dentin was left on the pulpal
floor; (B) the pulpal floor was covered with a glass ionomer liner; (C) the tooth was restored with a Class I OP amalgam restoration.
Treatment Technique
Due to moderate anxiety and apprehension,
•
treatment was performed under a 50% nitrous
oxide analgesia, with local anesthesia and
rubberdam
• Selective caries removal to soft dentin (IPT),
leavingthe soft dentin over the pulpal floor
(Figure3.1.4a)
• The soft dentin was covered with a light‐cured liner
containing glass ionomer. This material was chosen
due to its biocompatible properties, its ability to
promote remineralization of the demineralized dentin
and its fluoride release (Figure3.1.4b)
• The tooth was restored with a class I OP amalgam
restoration, due to its known sealing properties and
due to the poor compliance history (Figure3.1.4c)
M. Radiographic Follow‐Up
• Right and left bitewing radiographs six months
postoperative (Figure3.1.5)
N. Prognosis andDiscussion
• Prognosis for caries: the recommended protocol for
decreasing caries risk depends on the parent's
understanding and compliance in reducing the
A
Figure 3.1.5 Bitewing radiographs six months post‐treatment.
(A) Right bitewing radiograph; (B) left bitewing radiograph. On
maxillary left primary second molar note retraction of the
distal pulp horn due to the formation of reactionary dentin.
B
identified risk factors and in attending regular
recallexams. In the present case, the patient returned
for recall at three and six months as requested, but
the oral hygiene was still unsatisfactory,
toothbrushing was not regular, and the diet was still
highly cariogenic. The accumulated biofilm increased
the risk for caries and jeopardized the margins of the
restoration, favoring microleakage. Therefore, due to
poor compliance the prognosis for new and recurrent
caries is guarded
• Prognosis for selective caries removal to soft caries
(IPT): the prognosis for selective caries removal to
soft caries (IPT) is usually good. Selective caries
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removal in symptomless primary or permanent
teeth reduces the risk of pulp exposure. There is no
reported difference in the incidence of pulp
exposure, in the progression of the decay, and on
the longevity of restorations, irrespective of
whether the removal of decay had been minimal
(ultraconservative) or complete (Coll etal. 2017).
The success rate for this technique has been
reported to be higher than 90% in primary teeth.
However, its use is only recommended in patients
in whom a preoperative diagnosis suggests no
signs of pulp degeneration. Therefore, the value of
taking a good history complemented by a careful
clinical and radiographic examination cannot be
overemphasized
O. Common Complications andAlternative
Treatment Plans
• The most common complication of a failing IPT is
pulp necrosis and a periapical lesion. This complication
might be the result of an initial misdiagnosis of an
irreversibly inflamed or necrotic pulp, or due to a poor
restoration leading to microleakage
• In the present case, the longevity of the amalgam
restoration will depend on periodic clinical follow‐up
to check the integrity of the margins and rule out
microleakage. In addition, the presence of a new
proximal lesion might jeopardize the success of the
treatment. Thus, in children with high caries risk an
alternative approach would be to restore with a
stainless steel crown following an IPT
82 Clinical Cases inPediatric Dentistry
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Self‐Study Questions
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COMPLEX PULP THERAPY
1. What could have prevented the amount and
severity of the carious lesions?
2. Could a sealant have prevented initiation and
progression of the occlusal lesions?
3. IPT may spare the pulp, but does it reduce the
longevity of the restoration?
4. When is an IPT contraindicated for primary
molars?
5. How does poor compliance and high caries risk
inuence the choice of treatment?
Answers are located at the end of the case
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Self‐Study Answers
1. Better compliance with the recall protocol
recommended by the AAPD. At least the severity of
the lesions could have been better controlled and
new lesions may have been prevented
2. Probably yes. Sealants are indicated for primary
and permanent teeth with pits and fissures that are
predisposed to plaque retention
3. No. Systematic reviews of the literature
(Colletal. 2017) reported no difference in
thelongevity of restorations, irrespective of
Bibliography
American Academy of Pediatric Dentistry. 2018–2019. Use of
vital therapies in primary teeth with deep caries lesions. In:
Clinical Practice Guidelines and Best Practices (Reference
Manual). Pediatr Dent 40:179–92. https://www.aapd.org/
research/oral‐health‐policies‐‐recommendations/vital_pulp_
therapies_in_primary_teeth_with_deep_caries_lesions
Brannstrom M. 1984. Communication between the oral cavity
and the dental pulp associated with restorative treatment.
Oper Dent 9:57–68.
Coll JA, Seale NS, Vargas K etal. 2017. Primary tooth vital pulp
therapy: a systematic review and meta‐analysis. Pediatr
Dent 39:217–25.
Fuks AB. 2005. Pulp therapy for the primary dentition. In:
Pediatric Dentistry, Infancy Through Adolescence, 4th Edition
Pinkham JR, Casamassimo PS, McTigue DJ, Fields HW Jr.,
Nowak AJ (eds). Elsevier Saunders: St. Louis. p. 375–93.
Fuks A, Kupietzky A, Guelmann M. 2019. Pulp therapy for
theprimary dentition. In: Pediatric Dentistry: Infancy through
Adolescence, 6th edition. Nowak A, etal. (eds). Philadelphia:
Elsevier. p. 329.
Fuks A, Peretz B. 2016. Pediatric endodontic past and present
perspectives and future directions. In: Pediatric Endodontics.
Fuks AB, Peretz B (eds). Basel: Springer International
Publishing Switzerland.
Green D, Mackenzie L, Banerjee A. 2015. Minimally invasive
long‐term management of direct restorations: the ‘5rs’.
Dent Update 42:413–26, 2015.
whether the removal of decay had been minimal
(ultraconservative) or complete
4. IPT is contraindicated for primary molars when
there is a history of spontaneous pain or any clinical
or radiographic pathological signs
5. In patients with poor compliance and high caries
risk it is preferable to use more aggressive
treatment approaches, crowns instead of
multisurface restorations, for example
Guelmann M. 2016. Clinical pulpal diagnosis. In: Pediatric
Endodontics. Fuks AB, Peretz B (eds). Basel: Springer
International Publishing Switzerland.
Hilton TJ. 2009. Keys to clinical success with pulp capping:
areview of the literature. Oper Dent 34:615–25.
Innes NP, Frencken JE, Bjørndal L etal. 2016. Managing carious
lesions: consensus recommendations on terminology. Adv
Dent Res 28:49–57.
Maltz M, Garcia R, Jardim JJ et al. 2012. Randomized trial
ofpartial vs. stepwise caries removal. J Dent Res 91:102–31.
Murray PE, About I, Franquin JC etal. 2001. Restorative pulpal
and repair responses. J Am Dent Assoc 132:482–91.
Ricketts D, Lamont T, Innes NPT et al. 2013. Operative caries
management in adults and children. Cochrane Database
Syst Rev 28;3:CD003808.
Schwendicke F, Dörfer CE, Paris S. 2013. Incomplete caries
removal: a systematic review and meta‐analysis. J Dent Res
92:306–14.
Schwendicke F, Frencken JE, Bjorndal L etal. 2016. Managing
carious lesions: consensus recommendations on carious
tissue removal. Adv Dent Res 28:58–67.
Stanley HR. 1990. Pulpal responses to ionomer cements–bio-
logical characteristics. J Am Dent Assoc 120:25–9.
Ten Cate JM. 2001. Remineralization of caries lesions extend-
ing into dentin. J Dent Res 80:1407–11.
Yoshiyama M, Tay FR, Doi J et al. 2002. Bonding of self‐etch
and total etch adhesives to carious dentin. J Dent Res
81:556–60.
84 Clinical Cases inPediatric Dentistry
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COMPLEX PULP THERAPY
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Case 2
Partial Pulpotomy inTraumatized Primary Incisors
Medical History
D.
• No significant findings, no known food or drug
allergies, no medications, vaccinations are up to date
E.
Medical Consult
• Not applicable
F. Dental History
• Has dental home
• Eating habits include a balanced diet rich in proteins
and low in carbohydrates
• Fair oral hygiene habits, brushes twice daily with
parental supervision
• Uses toothpaste containing fluoride
• Optimal water fluoridation levels
• No history of previous trauma
Figure 3.2.1 Facial photograph.
A. Presenting Patient
• Four‐year‐, two‐month‐old Caucasian female
(Figure3.2.1)
• New patient presenting as an emergency
B. Chief Complaint
• Mother stated, “My daughter fell one hour ago while
playing with other children in the kindergarten yard
and fractured her two upper front teeth” (see
Chapter 4 for more information on managing
orofacial trauma)
C. Social History
• Second of three children
• Both parents are well educated
• Middle class, mother works part time
G. Extraoral Exam
• Ruled out head injury, mild swelling of the upper lip
H. Intraoral Exam
Soft Tissues
• Bruises on maxillary labial mucosa, gingival laceration
on maxillary anterior area, and laceration of the
maxillary labial frenum
Hard Tissues
• No significant findings
Occlusion Evaluation ofPrimary Dentition
• Mesial step molars, class I canines
Dental Exam
• Caries‐free primary dentition
• Maxillary central incisors with complicated crown
fractures, pulp exposures
• Mild sensitivity to percussion on both maxillary
central incisors
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Figure 3.2.2 Anterior maxillary periapical radiograph showing
crown fractures with pulp involvement.
• Physiologic mobility on both traumatized incisors
• Extremely apprehensive
I. Diagnostic Tools
• Anterior maxillary periapical radiograph (Figure3.2.2).
Bitewing radiographs were not taken because the
patient had recent periodical examinations at her
family dentist
J. Differential Diagnosis
• Complicated crown fractures of maxillary primary
central incisors
• Complicated crown-root fractures
• Complicated crown fractures associated with
subluxation
Figure 3.2.3 Placement of rubber dam after administration of
a local anesthetic.
K. Diagnosis andProblem List
Diagnosis
• Based on the history of pain, clinical examination, and
radiographic findings, the most probable diagnosis is
complicated crown fractures of maxillary primary
central incisors
Problem List
• Maxillary primary central incisors with exposed pulps
and pulp polyps needing urgent treatment
•
Patient is very apprehensive and has never had a local
anesthetic
L. Comprehensive Treatment Plan
• Immediate partial pulpotomy treatment of the
exposed pulps (Figures3.2.3–3.2.5)
• Restore with esthetic metal or ceramic crown or
composite strip crown (Figure3.2.6)
• Explanation to the mother of the importance of
maintaining the vitality of both teeth
• Behavioral management considerations (consider
using nitrous oxide analgesia)
• Follow‐up care including:
Postoperative and home care instructions
Recall plan
Figure 3.2.4 After pulp amputation, the area is rinsed with
saline, and hemostasis is achieved with cotton pellet pressure.
Figure 3.2.5 After hemostasis, the amputated areas are
covered with calcium hydroxide or mineral trioxide aggregate,
followed by intermediate restorative material.
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Figure 3.2.6 Completed restorations showing good esthetic
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results. The pulps remained vital.
• Radiographs should be taken after 3, 6, 12, 18, and
24months and thereafter at yearly intervals until
physiologic exfoliation of the teeth
M. Prognosis andDiscussion
• Long‐term studies have shown very high success
rates of pulp capping and partial pulpotomy with
respect to pulp survival. Radiographic evidence of
hard tissue closure of the perforation can be seen
three months after pulp capping
• The primary factor reducing pulp survival after
crown fracture is compromised pulp circulation
due to luxation injuries. Crown fracture with
concomitant luxation injury has been shown to
have an increased incidence of pulpal necrosis.
Cvek (1994) reported 96% success with partial
pulpotomy using calcium hydroxide (Ca(OH)2) on
traumatically exposed permanent pulps. Size of
the exposure or time between injury and
treatment was not critical as long as the
superficially inflamed pulp tissue was removed
before capping. These studies included both
mature teeth and teeth with immature roots. In a
long‐term follow‐up study of partial pulpotomy in
permanent teeth, those judged to be healed at
three years remained healed 10–15 years later
• Ca(OH)2 or mineral trioxide aggregate (MTA) can be
used as treatment modalities for traumatized primary
incisors with pulp exposure. In the past, there was a
belief that pulpotomy with Ca(OH)2 resulted in internal
root resorption. Today we know that most pulp
COMPLEX PULP THERAPY
dressing agents can lead to this pathologic
complication and may be due to the condition of
theexposed pulp. Because the pulp is normal in
traumatized exposures (except for the exposure
area),removing the affected tissue brings about
agood prognosis
FUNDAMENTAL POINT 1
Complicated Crown Fracture
• Definition: enamel‐dentin fracture with pulp
exposure
• Diagnosis: clinical and radiographic findings
reveal a loss of tooth structure with pulp
exposure
• Treatment objectives: maintain pulp vitality and
restore normal esthetics and function. Injured
lips, tongue, and gingiva should be examined for
tooth fragments
• Pulpal treatment alternatives are partial
pulpotomy, complete pulpotomy, pulpectomy,
and extraction
Primary Teeth
• Keep treatment as simple as possible, taking
into consideration the child’s behavior and the
life span of the tooth. Decisions often are based
on life expectancy of the traumatized primary
tooth and vitality of the pulpal tissue
• Risk of treatment and possible sequelae to the
permanent tooth should be assessed versus the
functional benefit resulting from treatment to
the primary tooth
FUNDAMENTAL POINT 2
Advantages ofPartial Pulpotomy
• Preserves cell‐rich coronal pulp
• Increases healing potential due to preserved
pulp
• Physiologic apposition of cervical dentin
• Obviates need for root canal therapy
• Preserves natural color and translucency
• Maintains pulp vitality
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BACKGROUND INFORMATION 1
Partial Pulpotomy (Cvek Pulpotomy) Indications
andTechnique
Indications: Traumatic Pulp Exposures
• Initially performed only in permanent teeth.
Presently, there is enough evidence that this
procedure can also be applied in primary teeth
Technique
• After the diagnosis is completed, the tooth is
anesthetized
• If possible, pulpal procedures should always be
performed under rubber dam isolation and aseptic
conditions to prevent further introduction of
microorganisms into the pulp tissues (Figure3.2.3).
Care must be taken when placing the rubber dam
on a traumatized tooth. If any loosening of the
tooth has occurred, the rubber dam clamps must
be applied to adjacent uninjured teeth
• In traumatically exposed pulps, only tissue judged
to be inflamed is removed. Cvek (1994) showed
that with pulp exposures resulting from traumatic
injuries, regardless of the size of the exposure or
the amount of lapsed time, pulpal changes are
characterized by a proliferative response with
inflammation extending only a few millimeters into
the pulp. When this hyperplastic, inflamed tissue is
removed (about2 mm), healthy pulp tissue is
encountered. Inteeth with carious exposure of the
pulp, it may be necessary to remove pulp tissue to
a greater depth toreach uninflamed tissue
• The instrument of choice for tissue removal in the
pulpotomy procedure is an abrasive diamond bur,
using high speed with adequate water cooling. This
technique has been shown to create the least
damage to the underlying tissue
• Care must be exercised to ensure removal of all
filaments of the pulp tissue coronal to the
amputation site; otherwise, hemorrhage will be
impossible to control
• After pulpal amputation, the preparation is
thoroughly washed with physiologic saline or sterile
water to remove all debris; the water is removed by
vacuum and cotton pellets (Figure3.2.4). Air should
not be blown on the exposed pulp, because it will
cause desiccation and tissue damage
• Hemorrhage is controlled by cotton pellets
slightly moistened with saline (i.e. wetted and
blotted almost dry) placed against the stumps of
the pulp. Completely dry cotton pellets should
not be used because fibers of the dry cotton will
be incorporated into the clot and, when removed,
will cause hemorrhage. Dry cotton pellets are
placed over the moist pellets, and slight pressure
is exerted on the mass to control the hemorrhage
• Hemorrhage should be controlled in this manner
within several minutes. It may be necessary to change
the pellets to control all hemorrhage. Ifhemorrhage
continues, the clinician must carefully check to be sure
that all filaments of the pulp coronal to the amputation
site were removed and that the site is clean
• Sodium hypochlorite (2.5% NaOCl) can be
placedon the exposure site to cause hemostasis
before pulp capping. It also has the beneficial
effect of killing bacteria. It was reported that when
used as a hemostatic agent there was no damage
to pulpal cells and it did not inhibit pulpal healing,
odontoblastic cell formation, or dentinal bridging
• If hemorrhage cannot be controlled, pulpal
amputation should be performed at a more apical
level. Once the hemorrhage is controlled, Ca(OH)2
or MTA is placed in the canal against the pulp
stump. A thin layer of intermediate restorative
material or flowable composite resin is placed
over the Ca(OH)2 or MTA and light cured
(Figure3.2.5); otherwise, the material would be
washed out during the acid etching procedure.
The tooth is then sealed with an etched bonded
composite strip crown restoration (Figure3.2.6)
N. Complications andAlternative
TreatmentPlans
• Unsuccessful partial pulpotomy can result in pulp
necrosis and/or a periapical abscess with or without a
fistula. These complications can be the result of chronic
irritation due to microleakage from an improperly
88 Clinical Cases inPediatric Dentistry
adapted crown. Another reason for failure can be
related to recurrent trauma, a relatively common
finding in young children. These complications can also
occur if the initial treatment was a pulpectomy
• Extraction is an alternative, but less desirable in a
young child
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