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

[drsnehamaheshwari]

Young permanent teeth

Vital pulp therapy for teeth diagnosed with a normal pulp or reversible pulpitis

Protective liner

A protective liner is a thinly-applied liquid placed on the pulpal surface of a deep cavity preparation, covering exposed dentin tubules, to act as a protective barrier between the restorative material or cement and the pulp. Placement of a thin protective liner such as calcium hydroxide, dentin bonding agent, or glass ionomer cement is at the discretion of the clinician. The liner must be followed by a well-sealed restoration to minimize bacterial leakage from the restoration-dentin interface.

• Indications: In a tooth with a normal pulp, when caries is removed for a restoration, a protective liner may be placed in the deep areas of the preparation to minimize pulp injury, promote pulp tissue healing, and/or minimize postoperative sensitivity.

• Objectives: The placement of a liner in a deep area of the preparation is utilized to preserve the tooth’s vitality, promote pulp tissue healing, and facilitate tertiary dentin formation. This liner must be followed by a well-sealed restoration to minimize bacterial leakage from the restoration-dentin interface. Adverse post-treatment signs or symptoms such as sensitivity, pain, or swelling should not occur.

Indirect pulp treatment

Indirect pulp treatment is a procedure performed in a tooth with a diagnosis of reversible pulpitis and deep caries that might otherwise need endodontic therapy if the decay was completely removed. In recent years, rather than complete the caries removal in 2 appointments, the focus has been to excavate as close as possible to the pulp, place a protective liner, and restore the tooth without a subsequent reentry to remove any remaining affected dentin. The risk of this approach is either an unintentional pulp exposure or irreversible pulpitis. More recently, the step-wise excavation of deep caries has been revisited and shown to be successful in managing reversible pulpitis without pulpal perforation and/or endodontic therapy. This approach involves a 2-step process. The first step is the removal of carious dentin along the dentin-enamel junction (DEJ) and excavation of only the outermost infected dentin, leaving a carious mass over the pulp. The objective is to change the cariogenic environment in order to decrease the number of bacteria, close the remaining caries from the biofilm of the oral cavity, and slow or arrest the caries development. The second step is the removal of the remaining caries and placement of a final restoration. The most common recom-mendation for the interval between steps is 3-6 months, allowing sufficient time for the formation of tertiary dentin and a definitive pulpal diagnosis. Critical to both steps of excavation is the placement of a well-sealed restoration. The decision to use a one-appointment caries excavation or a step-wise technique should be based on the individual patient circumstances since the research available is inconclusive on which approach is the most successful over time.

• Indications: Indirect pulp treatment is indicated in a permanent tooth diagnosed with a normal pulp with no symptoms of pulpitis or with a diagnosis of reversible pulpitis. The pulp is judged by clinical and radiographic criteria to be vital and able to heal from the carious insult.

• Objectives: The intermediate and/or final restoration should seal completely the involved dentin from the oral environment. The vitality of the tooth should be preserved. No post-treatment signs or symptoms such as sensitivity, pain, or swelling should be evident. There should be no radiographic evidence of internal or external root resorption or other pathologic changes. Teeth with immature roots should show continued root development and apexogenesis.