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

[drsnehamaheshwari]

Primary teeth

 

Vital pulp therapy for primary teeth diagnosed with ab 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.

• Indications: In a tooth with a normal pulp, when all caries is removed for a restoration, a protective liner may be placed in the deep areas of the preparation to minimize injury to the pulp, 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 tertiary dentin formation, and minimize bacterial microleakage. Adverse post-treatment clinical 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 deep carious lesion approximating the pulp but without signs or symptoms of pulp degeneration. The caries surrounding the pulp is left in place to avoid pulp exposure and is covered with a biocompatible material. A radiopaque liner such as a dentin bonding agent, resin modified glass ionomer, calcium hydroxide, zinc oxide/eugenol, or glass ionomer cement is placed over the remaining carious dentin to stimulate healing and repair. If calcium hydroxide is used, a glass ionomer or reinforced zinc oxide/eugenol material should be placed over it to provide a seal against microleakage since calcium hydroxide has a high solubility, poor seal, and low compressive strength. The use of glass ionomer cements or reinforced zinc oxide/eugenol restorative materials has the additional advantage of inhibitory activity against cariogenic bacteria. The tooth then is restored with a material that seals the tooth from microleakage. Interim therapeutic restorations (ITR) with glass ionomers can used for caries control in teeth with carious lesions that exhibit signs of reversible pulpitis. The ITR can be removed once the pulp’s vitality is determined and, if the pulp is vital, an indirect pulp cap can be performed. Current literature indicates that there is inconclusive evidence that it is necessary to reenter the tooth to remove the residual caries. As long as the tooth remains sealed from bacterial contamination, the prognosis is good for caries to arrest and reparative dentin to form to protect the pulp. Indirect pulp capping has been shown to have a higher success rate than pulpotomy in long term studies. It also allows for a normal exfoliation time.

Therefore, indirect pulp treatment is preferable to a pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis.

Indications: Indirect pulp treatment is indicated in a primary tooth with no pulpitis18 or with reversible pulpitis when the deepest carious dentin is not removed to avoid a pulp exposure.8 The pulp is judged by clinical and radiographic criteria to be vital and able to heal from the carious insult.

Objectives: The restorative material should seal completely the involved dentin from the oral environment. The tooth’s vitality 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 pathologic external or internal root resorption or other pathologic changes. There should be no harm to the succedaneous tooth.