AAPD’s guidelines on pulp therapy for primary and immature permanent teeth

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Direct pulp cap

When a pinpoint mechanical exposure of the pulp is encountered during cavity preparation or following a traumatic injury, a biocompatible radiopaque base such as mineral trioxide aggregate (MTA) or calcium hydroxide may be placed in contact with the exposed pulp tissue. The tooth is restored with a material that seals the tooth from microleakage.

• Indications: This procedure is indicated in a primary tooth with a normal pulp following a small mechanical or traumatic exposure when conditions for a favorable response are optimal. Direct pulp capping of a carious pulp exposure in a primary tooth is not recommended.

• Objectives: The tooth’s vitality should be maintained. No post-treatment signs or symptoms such as sensitivity, pain, or swelling should be evident. Pulp healing and reparative dentin formation should result. There should be no radiographic signs of pathologic external or progressive internal root resorption or furcation/apical radiolucency. There should be no harm to the succedaneous tooth.

Pulpotomy

A pulpotomy is performed in a primary tooth with extensive caries but without evidence of radicular pathology when caries removal results in a carious or mechanical pulp exposure. The coronal pulp is amputated, and the remaining vital radicular pulp tissue surface is treated with a long-term clinically- successful medicament such as Buckley’s Solution of formocresol or ferric sulfate. Electrosurgery also has demonstrated success. Gluteraldehyde and calcium hydroxide have been used but with less long-term success. MTA is a more recent material used for pulpotomies with a high rate of success. Clinical trials show that MTA performs equal to or better than formocresol or ferric sulfate and may be the preferred pulpotomy agent in the future. After the coronal pulp chamber is filled with zinc/oxide eugenol or other suitable base, the tooth is restored with a restoration that seals the tooth from microleakage. The most effective long-term restoration has been shown to be a stainless steel crown. However, if there is sufficient supporting enamel remaining, amalgam or composite resin can provide a functional alternative when the primary tooth has a life span of 2 years or less.

• Indications: The pulpotomy procedure is indicated when caries removal results in pulp exposure in a primary tooth with a normal pulp or reversible pulpitis or after a traumatic pulp exposure. The coronal tissue is amputated, and the remaining radicular tissue is judged to be vital without suppuration, purulence, necrosis, or excessive hemorrhage that cannot be controlled by a damp cotton pellet after several minutes, and there are no radiographic signs of infection or pathologic resorption.

• Objectives: The radicular pulp should remain asymptomatic without adverse clinical signs or symptoms such as sensitivity, pain, or swelling. There should be no postoperative radiographic evidence of pathologic external root resorption. Internal root resorption can be self limiting and stable. The clinician should monitor the internal resorption, removing the affected tooth if perforation causes loss of supportive bone and/or clinical signs of infection and inflammation. There should be no harm to the succedaneous tooth.