BEST PRACTICES: PULP THERAPY Pulp Therapy for Primary and Immature Permanent Teeth Latest Revision How to Cite: American Academy of Pediatric Dentistry. Pulp therapy 2020 for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:384-92. Purpose as: normal pulp (symptom free and normally responsive to The American Academy of Pediatric Dentistry AAPD( ) intends vitality testing), reversible pulpitis (pulp is capable of healing), these recommendations to aid in the diagnosis of pulp health symptomatic or asymptomatic irreversible pulpitis (vital versus pathosis and to set forth the indications, objectives, inflamed pulp is incapable of healing), or necrotic pulp.3 The and therapeutic interventions for pulp therapy in primary and clinical diagnosis derived from:4-7 immature permanent teeth. 1. a comprehensive medical history. 2. a review of past and present dental history and Methods treatment, including current symptoms and chief Recommendations on pulp therapy for primary and immature complaint. permanent teeth were developed by the Clinical Affairs 3. a subjective evaluation of the area associated with the Committee – Pulp Therapy Subcommittee and adopted in current symptoms/chief complaint by questioning 1991.1 This document by the Council of Clinical Affairs is the patient/parent on the location, intensity, a revision of the previous version, last revised in 2014.2 This duration, stimulus, relief, and spontaneity. revision included a new search of the PubMed / 4. an objective extraoral examination as well as examina- MEDLINE database using the terms: pulpotomy, pulpectomy,® tion of the intraoral soft and hard tissues. pulpectomy primary teeth, indirect pulp treatment (IPT), 5. if obtainable, radiograph(s) to diagnose periapical or stepwise excavation, pulp therapy, pulp capping, pulp periradicular changes. exposure, bases, liners, calcium hydroxide, formocresol, ferric 6. clinical tests such as palpation, percussion, and sulfate, glass ionomer, mineral trioxide aggregate (MTA), mobility; however, electric pulp and thermal tests are bacterial microleakage under restorations, lesion sterilization unreliable in immature permanent and primary teeth. tissue repair (LSTR), dentin bonding agents, resin modified glass ionomers, and endodontic irrigants; fields: all. Papers Teeth exhibiting provoked pain of short duration relieved for review were chosen from the resultant lists and from with over-the-counter analgesics, by brushing, or upon the hand searches. When data did not appear sufficient or were removal of the stimulus and without signs or symptoms of inconclusive, recommendations were based upon expert and/ irreversible pulpitis have a clinical diagnosis of reversible pulp- or consensus opinion including those from the 2007 joint itis and are candidates for vital pulp therapy. Teeth diagnosed symposium of the AAPD and the American Association of with a normal pulp requiring pulp therapy or with reversible Endodontists (AAE) titled Emerging Science in Pulp Therapy: pulpitis should be treated with vital pulp therapy.8-11 New Insights into Dilemmas and Controversies (Chicago, Ill.) Teeth exhibiting signs or symptoms such as a history of spontaneous unprovoked pain, a sinus tract, soft tissue inflam- Background mation not resulting from gingivitis or periodontitis, excessive The primary goal of pulp therapy is to maintain the integrity mobility not associated with trauma or exfoliation, furcation/ and health of the teeth and their supporting tissues while apical radiolucency, or radiographic evidence of internal/ maintaining the vitality of the pulp of a tooth affected by external resorption have a clinical diagnosis of irreversible pulp- caries, traumatic injury, or other causes. Especially in young itis or necrosis and are candidates for nonvital pulp treatment.12 permanent teeth with immature roots, the pulp is integral to continue apexogenesis. Long term retention of a permanent tooth requires a root with a favorable crown/root ratio and ABBREVIATIONS dentinal walls that are thick enough to withstand normal AAE: American Association of Endodontists. AAPD: American function. Therefore, pulp preservation is a primary goal for Academy of Pediatric Dentistry. DPC: Direct pulp cap. IPT: Indirect treatment of the young permanent dentition. pulp therapy. ITR: Interim therapeutic restoration. LSTR: Lesion sterilization/tissue repair. MTA: Minera ltrioxide aggregate. ZOE: The indications, objectives, and type of pulpal therapy are Zinc oxide eugenol. based on the health status of the pulp tissue which is classified 384 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY BEST PRACTICES: PULP THERAPY Regenerative endodontics may be considered for immature Primary teeth permanent teeth with apical periodontitis, a necrotic pulp, and Vital pulp therapy for primary teeth diagnosed with a normal immature apex.13 pulp or reversible pulpitis Protective liner. A protective liner is a thinly-applied material Recommendations placed on the dentin in proximity to the underlying pulpal All relevant diagnostic information, treatment, and treatment surface of a deep cavity preparation, covering exposed dentin follow-up shall be documented in the patient’s record. tubules to act as a protective barrier between the restorative Any planned treatment should include consideration of: material or cement and the pulp. Placement of a thin protective 1. the patient’s medical history; liner such as MTA, trisilicate cements, calcium hydroxide, or other 2. the value of each involved tooth in relation to the biocompatible material is at the discretion of the clinician.19,20 child’s overall development; • Indications: In a tooth with a normal pulp when all caries 3. alternatives to pulp treatment; and is removed for a restoration, a protective liner may be placed 4. restorability of the tooth. in the deep areas of the preparation to minimize injury to the pulp, promote pulp tissue healing, and/or minimize When the infectious process cannot be arrested by the post-operative sensitivity.21,22 treatment methods included in this section, bony support • Objectives: The placement of a liner in a deep area of the cannot be regained, inadequate tooth structure remains for preparation is utilized to preserve the tooth’s vitality, pro- a restoration, or excessive pathologic root resorption exists, mote pulp tissue healing and tertiary dentin formation, and extraction should be considered.4,12 minimize bacterial microleakage.23 Adverse post-treatment This document is intended to recommend the best available clinical signs or symptoms such as sensitivity, pain, or clinical care for pulp treatment, but the AAPD encourages swelling should not occur. additional research for consistently successful and predictable techniques using biologically-compatible medicaments for Indirect pulp treatment. IPT is a procedure performed in a vital and non-vital primary and immature permanent teeth. tooth with a deep caries lesion approximating the pulp but Pulp therapy requires periodic clinical and radiographic assess- without evidence of radicular pathology. “Indirect pulp treat- ment of the treated tooth and the supporting structures.14 ment is a procedure that leaves the deepest caries adjacent to Post-operative clinical assessment generally should be performed the pulp undisturbed in an effort to avoid a pulp exposure. every six months and could occur as part of a patient’s periodic This caries-affected dentin is covered with a biocompatible comprehensive oral examination. Patients treated for an acute material to produce a biological seal.”17 A radiopaque liner such dental infection initially may require more frequent clinical as a dentin bonding agent,24,25 resin modified glass ionomer,4 reevaluation. A radiograph of a primary tooth pulpectomy calcium hydroxide,25 or MTA (or any other biocompatible should be obtained immediately following the procedure.5 This material)26 is placed over the remaining carious dentin to can document the quality of the fill and help determine the stimulate healing and repair. The liner that is placed over the tooth’s prognosis. This image also would serve as a comparative dentin (calcium hydroxide, glass ionomer, or bonding agents) baseline for future films (the type and frequency of which are does not affect the IPT success.27 The tooth then is restored at the clinician’s discretion). Radiographic evaluation of primary with a material that seals the tooth from microleakage. tooth pulpotomies should occur at least annually because the Interim therapeutic restorations (ITR) with glass ionomer success rate of pulpotomies diminishes over time.15 Bitewing cements may be used for caries control in teeth with carious radiographs obtained as part of the patient’s periodic compre- lesions that exhibit signs of reversible pulpitis. The ITR can hensive examinations may suffice. If a bitewing radiograph be removed once the pulp’s vitality is determined and, if the does not display the interradicular area, a periapical image is pulp is vital, an indirect pulp cap can be performed.15,28 Current indicated. Immature permanent teeth treated with pulp therapy literature indicates that there is no conclusive evidence that it also should have close clinical and radiographic follow-up to is necessary to reenter the tooth to remove the residual caries.29,30 confirm that pulpal pathology is not developing.16 Isolation is As long as the tooth remains sealed from bacterial contami- necessary