PERMANENT TOOTH PULP THERAPY

DIFFERENTIAL DIAGNOSIS AND CONTRAINDICATIONS

1. The Indirect Pulp Cap

Contraindications: Same as for primary teeth except for the information regarding root resorption.

2. The Direct Pulp Cap
The following must hold true:

1. The exposure is surgical, not carious.
2. There is evidence of vital tissue e.g. a small amount of bleeding.
3. There is no history of spontaneous pain.
4. All contra-indications as for the indirect pulp cap.

3. The Pulpotomy
A) Indications

1. Vital pulp exposure secondary to dental fracture:

a) pulp exposure greater than 1mm
b) a coronal pulp exposure of any size being treated more than 2 hours but no more than 24 hours after trauma in a tooth with an incomplete apex.

2. Carious pulp exposure of vital pulp in permanent tooth with incomplete apices.

3. The pulpotomy is rarely used as a definitive long-term solution to pulpal problems in the permanent dentition. It is useful in young permanent teeth to permit root completion.

B) Partial Pulpotomy is possible for permanent teeth; the remaining tissue is covered with calcium hydroxide after control of bleeding with sterile cotton pellets.

C) Contra-indications:

1. Evidence of pulpal necrosis

a) non-restorable tooth
b) periapical pathology
c) fistula
d) abnormal mobility
e) discoloration
f) internal/external root resorption

4. Apexification

This procedure precedes conventional root canal therapy in the management of teeth with irreversible diseased pulps and open apices.

5. Apexogenesis

Indications

1) vital pulp with incomplete apical development
2) pulp exposure greater than "1" mm

6. Calcium-Hydroxide Root Canal Treatment

This procedure is usually performed on severely intruded or avulsed permanent teeth. Ca (OH)2 filling reduces the chance of external root resorption.

GENERAL CONSIDERATIONS:
For vital pulp therapy to succeed, meticulous attention must be paid to principles of sterility. The affected tooth must be well-isolated with rubber dam to prevent exposure of the pulp saliva and organisms such as bacteria and spores. Instruments which have been used to remove carious material should not be introduced into the pulp chamber. Use of an intra-pulpal injections is never indicated in vital pulp therapy. (The pressure induced by the injection of a local anesthetic solution into the pulp chamber may cause irreversible damage to the remaining radicular pulp tissue). In most cases, the temporary restorative material of choice is IRM rather than Cavit. Cavit is a hydrophilic material and, therefore, tends to dehydrate the remaining vital pulp.