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COMPLEX PULP THERAPY
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• However, there is disagreement among clinicians about
the utility of pulpectomy procedures in primary teeth.
Difficulty in the preparation of primary root canals that
have complex and variable morphologic features and the
uncertainty about teeth with gross loss of root structure;
advanced internal or external or periapical resorption;
and the effect of instrumentation, medication, and filling
materials on developing succedaneous teeth dissuade
some clinicians from using the technique. The behavior
management problems that sometimes occur in
pediatric patients have surely added to the reluctance
among some dentists to perform RCT in primary teeth.
These problems notwithstanding, the success of
pulpectomies in primary teeth has led most pediatric
dentists to prefer them to the alternative of extractions
and space maintenance
BACKGROUND INFORMATION 1
Root Canal Treatment inPrimary Molars
• RCT can be performed in primary molars with
irreversible pulpitis, determined as continuous
bleeding exceeding five minutes or pulp necrosis.
Radiographic periapical or interradicular
radiolucencies, without involvement of the follicle
of the permanent tooth, are considered indications
for RCT. The same is true for teeth with internal
resorption without perforation and for those with
external resorption not involving the permanent
tooth follicle, as long as more than two‐thirds of
the root is intact (Moskovitz and Tickotsky 2016)
Technique
• RCT is usually completed in one visit. Under local
anesthesia and rubber dam isolation, caries are
removed and access to the pulp chamber is gained.
The inflamed or necrotic pulp is then removed and
mechanical preparation of the canal is performed
using a series of 21mm K‐type endodontic files
(Unitek Corp., Monrovia, CA) up to file no. 30. The
working length is estimated from the preoperative
radiograph. The root canals are then irrigated with
alternating chlorhexidine or sodium hypochloride
and saline, and dried with paper points. Because
the morphology of the root canal system in primary
teeth is extremely complex and difficult to clean
mechanically, chemical disinfection is more
effective
• Certain clinical situations may justify pulpectomy even
with the knowledge that the prognosis may not be ideal.
An example of such a case is pulp destruction of a
primary second molar that occurs before the first
permanent molar erupts. A premature extraction of the
primary second molar without placement of a space
maintainer usually results in mesial eruption of the first
permanent molar with subsequent loss of space for the
second premolar. Although a distal shoe space
maintainer could be used, maintaining the natural tooth
is definitely the treatment of choice. Therefore, a
pulpectomy in a primary second molar is preferable, even
if that tooth is maintained only until the first permanent
molar has adequately erupted and is followed eventually
by extraction of the primary second molar and placement
of a space maintainer (Fuks etal. 2019)
• A root canal filling material containing iodoform is
introduced into the root canal using a lentulo spiral
mounted on a slow speed handpiece, and the teeth
are sealed with reinforced zinc oxide eugenol (ZOE)
• A postoperative radiograph is taken after each
treatment to determine the extent of the filling
material in the canals. Overfilling canals tend to
result in more failures of the RCT
• The patient is asked to return up to one month later
for coronal restoration. In the absence of clinical
primary molars are restored with an amalgam, glass
ionomer, or composite restoration if sufficient tooth
structure remains to allow retention of the
restoration. Otherwise, a crown is used. The
estimated time left until natural shedding, determined
by the extent of physiologic root resorption, also may
influence the type of restoration to be placed
Evaluation ofRCT
• Patients should return every six months for recall
examinations in which the root‐treated molars are
evaluated clinically and radiographically. RCT is
considered successful if the tooth is painless and
presents healthy surrounding soft tissues and normal
mobility, and if radiographs show decrease or no
change in the pre‐existing pathologic radiolucent
defects. The treatment is considered a failure when
pre‐existing radiolucent defects grow in size or new
defects appear (Smaïl‐Faugeron etal. 2013)
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O. Common Complications andAlternative
Treatment Plans
• Enlargement of a previously existing periapical or
interradicular radiolucency and the development of a
new lesion in a tooth without a preoperative pathologic
radiolucency are real failures and should eventually be
extracted. However, in cases in which the preoperative
radiolucency remains unchanged, the patient should be
recalled in six months for re‐evaluation. Unsuccessful
RCT in a primary tooth may result in its premature
exfoliation due to pathologic root resorption that can be
followed by premature eruption of the permanent
successor. Cystic lesions have been described less
frequently as complications of primary RCTs
• The dentigerous cyst is an uncommon complication
of RCT in primary molars. The cystic lesion in
Figure3.4.6 was observed six and a half years after
the successful endodontic treatment presented
above. Extraction of the exfoliating primary molar and
marsupialization of the cyst resulted in normal
eruption and occlusion of the permanent premolar
Figure 3.4.6 Radiograph showing dentigerous cyst as a
complication of root canal treatment in a primary molar
(seearrow at border of cyst).
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Self‐Study Questions
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COMPLEX PULP THERAPY
1. What are the indications for a pulpectomy
according to the Guidelines of the American
Academy of Pediatric Dentistry?
2. When is an RCT contraindicated for primary molars?
3. What are the radiographic signs of RCT failure,
and how should they be handled?
4. What is more effective for disinfection of the
root canal system in primary teeth: mechanical or
chemical debridement?
Answers are located at the end of the case
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Self‐Study Answers
1. In teeth with carious exposure in which the
radicular pulp exhibits clinical signs of hyperemia or
evidenceof necrosis of the radicular pulp, with or
without caries involvement, following coronal pulp
amputation
2. In teeth with nonrestorable crowns, with
perforation of the pulpal floor, with internal
resorption perforating into the underlying bone,
with external resorption of more than one‐third
ofthe root, or involving the follicle of the
permanenttooth
Bibliography
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.
Moskovitz M, Sammara E, Holan G. 2005. Success rate of root
canal treatment in primary molars. J Dent 33:41–7.
Moskovitz M, Tickotsky N. 2016. Pulpectomy and root canal
treatment (RCT) in primary teeth: techniques and materials.
3. Enlargement of a previously existing periapical or
interradicular radiolucency and the development of a
new lesion in a tooth without a preoperative pathologic
radiolucency are real failures and should eventually be
extracted. However, in cases in which the preoperative
radiolucency remains unchanged, the patient should
be recalled in another six months for re‐evaluation
4. Because the morphology of the root canal
systemin primary teeth is extremely complex and
difficult to clean mechanically, chemical disinfection
is more effective
In: Pediatric Endodontics: Current Concepts in Pulp Therapy
for Primary and Young Permanent Teeth. Fuks AB, Peretz B
(eds). Basel: Springer International Publishing Switzerland.
Smaïl‐Faugeron V, et. al. 2013. Development of a core set of
outcomes for randomized controlled trials with multiple
outcomes ‐ example of pulp treatments of primary teeth for
extensive decay in children. PLoS One 8(1):e51908.
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COMPLEX PULP THERAPY
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Case 5
Partial Pulpotomy inaCariously Exposed Young
PermanentMolar
F. Dental History
• History of pain for five days while eating
sweetsordrinking cold beverages with no
swellingobserved
• Has received extensive restorative treatment
• Highly cariogenic diet
• Poor oral hygiene habits, with little adult supervision
• Uses toothpaste containing fluoride
• Optimal water fluoridation levels
• No history of trauma
Figure 3.5.1 Facial photograph.
A. Presenting Patient
• Eight‐year‐, six‐month‐old Hispanic male (Figure3.5.1)
• Patient of record presenting for an emergency
B. Chief Complaint
Mother confirmed the patient’s complaint of pain in the
•
lower right quadrant for five days. The pain subsides
after a few minutes, without taking analgesics
C. Social History
• Oldest of three children
• Single mother
• Middle socioeconomic class
D. Medical History
• No significant findings, no known drug or food
allergies, no medications, vaccinations up to date
E. Medical Consult
• Not applicable
G. Extraoral Exam
• No significant findings
H. Intraoral Exam
Soft Tissues
• Plaque‐induced gingivitis
Hard Tissues
• No significant findings
Occlusal Evaluation ofMixed Dentition
• Class I molars and canines
Dental Exam
• Generalized plaque accumulation
• Several teeth with extensive restorations
• Extensive caries present in the maxillary primary
second molars, maxillary first permanent molars, and
all mandibular molars
I. Diagnostic Tools
• Two bitewing radiographs showing multiple carious
lesions (Figure3.5.2)
• Periapical radiograph of the mandibular right first
permanent molar could not be obtained because of
severe gag reflex
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A
A
Figure 3.5.2 Preoperative bitewing radiographs. (A)
Preoperative right bitewing radiograph (arrow at deep lesion);
(B) preoperative left bitewing radiograph.
B
B
J. Differential Diagnosis
• Deep, carious lesion in the mandibular right first
permanent molar with possible:
Reversible pulp inflammation
Irrreversible pulp inflammation
Partial pulp necrosis
Total pulp necrosis
K. Diagnosis andProblem List
Diagnosis
• Based on the history of pain, the clinical examination,
and the radiographic findings, the most probable
diagnosis is extensive carious lesion with reversible
pulp inflammation
Problem List
High caries risk due to several factors (cariogenic
•
diet, poor oral hygiene with extensive plaque
accumulation)
• Deep, carious lesion (Figure3.5.2a, arrow)
• Poor compliance with dental appointments
• Premature loss of maxillary right primary first molar:
concern for space maintenance
• Behavior management: extremely apprehensive with
severe gag reflex
L. Comprehensive Treatment Plan
• Urgent treatment of the carious lesion of the
mandibular right first permanent molar with partial
pulpotomy and amalgam restoration
• Explanation to the mother of the importance of
maintaining the first permanent molar for a proper
occlusion
•
Behavioral management considerations: nitrous oxide
analgesia
• Comprehensive treatment of other carious lesions
• Establishment of a caries prevention plan
• Follow‐up care including:
Postoperative and home care instructions
Appropriate prevention and recall plans
• Any necessary consultations (orthodontic,
endodontic, oral surgery, etc.)
BACKGROUND INFORMATION 1
Partial Pulpotomy forYoung Permanent
PosteriorTeeth
• A partial pulpotomy is indicated in a young
permanent tooth for a small (<2 mm) carious
exposure in which the pulpal bleeding can be
controlled in one to two minutes. The tooth
mustbe vital, with a diagnosis of normal pulp
orreversible pulpitis. The procedure is usually
reserved for teeth with little or no history of
pain,absence of radiographic signs of pathology,
percussion sensitivity, swelling, or mobility
(American Academy of Pediatric Dentistry [AAPD]
2018–2019)
• The procedure involves the removal of pulp tissue
beneath the exposure site judged to be inflamed
(usually 1–3 mm) to reach healthy tissue below.
Pulpal bleeding must be controlled quickly and the
104 Clinical Cases inPediatric Dentistry
site should be covered with calcium hydroxide
(Ca(OH)2) or mineral trioxide aggregate (MTA),
followed by a restoration that seals the tooth from
microleakage (Chailertvanitkul etal. 2014)
• Before initiating treatment, it is critical to evaluate the
degree of pulp inflammation in an attempt to
distinguish between reversible and irreversible
pulpitis. Vital pulp therapy in permanent teeth with
history of pain has traditionally been considered
contraindicated. Although the correlation between
clinical and histologic evaluation is poor, young
permanent teeth are good candidates for this
conservative treatment because their rich blood
supply enhances healing ability. Because the loss of
the pulp in immature teeth can complicate treatment,
it seems advisable to attempt the partialpulpotomy
procedure. If failure occurs, apexification can be
attempted (Camp and Fuks2006)
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COMPLEX PULP THERAPY
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A
Figure 3.5.3 Postoperative bitewing radiographs. (A)
Postoperative right bitewing radiograph (arrow at dentin
bridge); (B) postoperative left bitewing radiograph.
Figure 3.5.4 Three years and 10 months postoperative right
bitewing radiograph.
B
M. Radiographic Follow‐Up
• Postoperative radiographs at nine months
(Figure3.5.3): a dentin bridge can be seen under the
amputated pulp horn in the mandibular right
permanent first molar (arrow). The two left mandibular
primary molars were treated with pulpotomies
followed by stainless steel crowns, and the maxillary
left primary second molar was extracted
• Postoperative radiographs at 3 years, 10 months
(Figure3.5.4): in the mandibular right first permanent
molar the pulp appears within normal limits but there
are signs of breakdown of the restoration
• Postoperative radiograph at four years, nine months
(Figure3.5.5): the pulp still appears sound but the
restoration has now been replaced with a stainless
steel crown
Prognosis andDiscussion
N.
• Long‐term studies have shown very high success
rates of pulp capping and partial pulpotomy with
respect to pulp survival. Radiographic evidence of
Figure 3.5.5 Four years and nine months postoperative right
bitewing radiograph.
hard tissue closure of the perforation can be seen
three months after pulp capping in this case
•
Mejare and Cvek (1993) reported a success rate of
91% in cases with no clinical or radiographic signs of
pathology after a follow‐up of 24–140 months. The
same study reported that four of six cases with
temporary pain and radiographic signs of minor
periapical involvement responded successfully.
Another study (Mass and Zilberman 1993) also
reported a success rate of 91% in 35 cases followed
for 12–48 months
Cvek and colleagues (1978, 1982) have reported 96%
•
success with pulp capping and pulpotomy using
Ca(OH)
on traumatically exposed permanent pulps.
2
The 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. Subsequent investigations have
verified these findings
• Histological examination of pulps from teeth
successfully treated with partial pulpotomy and
removed for restorative purposes showed no
significant pathological changes (Cvek etal. 1982)
O. Common Complications andAlternative
Treatment Plans
• Unsuccessful partial pulpotomy in an immature
permanent molar might result in pulp necrosis and
eventually a periapical abscess. These cases must be
followed by an apexification or apical barrier
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Self‐Study Questions
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COMPLEX PULP THERAPY
1. What are the indications for a partial pulpotomy
in a young permanent tooth?
2. Why are young carious permanent molars good
candidates for conservative treatments such as
partial pulpotomy?
3. What are the complications of a partial pulpotomy
failure in an immature permanent molar?
4. Why is bleeding control a diagnostic tool for the
diagnosis of the pulp condition?
Answers are located at the end of the case
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Self‐Study Answers
1. A partial pulpotomy is indicated in a young
permanent tooth for a small (<2 mm) carious exposure
in which the pulpal bleeding can be controlled in one
to two minutes. The tooth must be vital, with a
diagnosis of normal pulp or reversible pulpitis
2. Young permanent teeth are good candidates for
this conservative treatment because of their rich
blood supply that enhances the healing capacity of
the pulp
Bibliography and Additional Reading
American Academy of Pediatric Dentistry. 2018–2019. Pulp
therapy for primary and immature permanent teeth. In:
Clinical Practice Guidelines and Best Practices (Reference
Manual). Pediatr Dent 40:343–51. https://www.aapd.org/
research/oral‐health‐policies‐‐recommendations/pulp‐
therapy‐for‐primary‐and‐immature‐permanent‐teeth
Camp J, Fuks AB. 2006. Pediatric endodontics: endodontic
treatment for the primary and young, permanent dentition.
In: Pathway of the Pulp, 9th edition. Cohen S, Hargreaves
KM (eds). St Louis: Elsevier. pp. 822–82.
Chailertvanitkul P et al. 2014. Randomized control trial compar-
ing calcium hydroxide and mineral trioxide aggregate for
partial pulpotomies in cariously exposed pulps of permanent
molars. Int Endod J 47(9):835–42.
3. Failure of a partial pulpotomy may result in pulp
necrosis and/or a periapical abscess. This would in
turn require an apexification procedure
4. Usually when bleeding does not stop after one to
two minutes there is hyperemia or pulp
inflammation, decreasing the prognosis for a
successful partial pulpotomy
Cvek M. 1978. A clinical report on partial pulpotomy and
capping with calcium hydroxide in permanent incisors
withcomplicated crown fractures. J Endod 4:232–7.
Cvek M, Cleaton‐Jones P, Austin J, Andreasen JO. 1982.
Pulp reactions to exposure after experimental crown
fractures or grinding in adult monkeys. J Endod 8:391–7.
Fuks A, Nuni E. 2019. Pulp therapy for the young permanent
dentition. In: Pediatric Dentistry: Infancy through
Adolescence, 6th edition. Nowak A, etal. (eds). Philadelphia:
Elsevier. p. 482.
Mass E, Zilberman U. 1993. Clinical and radiographic evaluation
of partial pulpotomy in carious exposures of permanent
molars. Pediatr Dent 15:257–9.
Mejare I, Cvek M. 1993. Partial pulpotomy in young permanent teeth
with deep carious lesions. Endod Dent Traumatol 9:238–42.
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