DIFFERENTIAL DIAGNOSIS AND CONTRAINDICATIONS
I. The Indirect Pulp Cap
Contraindications:
1. Non-restorable tooth
2. Evidence of pulpal necrosis
a) Periapical or intraradicular pathology
b) Fistula
c) Abnormal mobility
d) Discoloration3. More than 2/3 of the root is absorbed
4. History of spontaneous discomfort
5. Exposure of the pulp
II. The Direct Pulp Cap (rarely used)
The following must hold true:1. The exposure is surgical (mechanical) not carious.
2. There is evidence of vital tissue, e.g. small amount of bleeding.
3. There is no history of spontaneous pain
4. Other contraindications as for the indirect pulp cap.
III. The Pulpotomy
The following are contraindications to the pulpotomy:1. Evidence of pulpal necrosis (as for the indirect pulp cap).
2. More than 2/3 of the root is resorbed.
3. History of spontaneous discomfort.
4. The tooth is non-restorable
IV. Complete Endodontics (pulpectomy)
The following are contraindications to the pulpectomy:1. A fistula is located in the attached gingiva or is through the sulcus (note: that a fistula in the muco buccal fold is not contraindication to a pulpectomy).
2. More than 2/3 of the root is resorbed or alveolar emergence of the permanent tooth has occurred.
3. Periapical pathology is greater than ½ of the intradicular space.
4. The tooth is non-restorable.
V. Contraindications to both the Pulpotomy and Pulpectomy
The patient has a chronic illness or requires prophylactic antibiotics on a day to day basis (not only for dental care). The reasoning behind this general contraindication is that when pulp therapy fails, it's failure is routinely asymptomatic. The contraindication is not based on bacteremia produced by the procedure. On the contrary, pulp therapy induces significantly less bacteremia than extraction of the same tooth. The concern for the chronically ill child is that the symptomless failure and colonization of bacteria in the necrotic site will induce continual unknown bacteremia with attendant systemic complications.