I. EXAMINATION AND DIAGNOSIS
Treatment planning for pulp therapy in children and adolescents should not be undertaken until an adequate medical and dental history has been taken. Visual and radiographic examinations should provide the basic information, but additional tests such as palpation, mobility, and percussion are often indicated. It may be necessary to take periapical or occlusal films to augment caries-control films such as bitewings.
II. TREATMENT PLANNING, RECORDS AND RECALLS
Appropriate treatment is predicated on the acquisition and analysis of all diagnostic data. Treatment planning should include an evaluation of the value of each tooth in the overall developmental process and alternatives to its retention.
Treatment records should include the chief complaint(s) (child's or parent's) clinical impression, results of clinical examination, diagnosis and treatment, required pre-operative, intra-operative, and post-operative radiographs. Follow-up radiographs should be taken when warranted. All teeth treated for pulp protection or involvement should be followed-up and re-evaluated, clinically and radiographically on a periodic basis.
III. PRIMARY TEETH
A. Vital Pulp Therapy
1. Protective base
Procedure: An appropriate material is placed at the base of preparation to seal the dentinal tubules and to act as a protective barrier to minimize further pulp injury and permit the pulp tissue to heal.
Objectives:
· A radiopaque protective base material should be placed between the restorative and the dentin surface.
· The procedure is performed to prevent adverse clinical signs and symptoms
· The procedure is performed to preserve the health and vitality of the restored tooth.
2. Indirect Pulp Treatment
Procedure: In a tooth with a deep carious lesion, complete carious dentin removal is delayed, and the decay process is sealed with an appropriate restorative material. The purpose is to stop the progression of the carious process, protect the pulp against further injury and allow reparative dentin formation.
Objectives:
· A radiopaque base should be placed over the remaining affected dentin, but not in contact with the pulp tissue.· The purpose of the procedure is to stop the carious process, permit pulp healing and reparative dentin formation.
· The procedure is intended to avoid internal resorption or other pathologic changes as determined by periodic radiographic evaluation.3. Direct Pulp Capping
Procedure: Direct pulp capping in a primary tooth with a carious exposure is not recommended due to the high failure rate as compared to the greater success of pulpotomy procedures. This procedure is valid for small mechanical or traumatic exposures in primary teeth when conditions for a favorable pulpal restorative response are optimal.
Objectives:
· A radiopaque protective base should be gently and without pressure placed in contact with the exposed pulp tissue.
· The objective of the base is to permit pulp healing and reparative dentin formation.
· The purpose is to prevent further pulp damage and to avoid clinical signs and symptoms.
· The procedure is intended to avoid pathologic changes as determined by periodic radiographic evaluation.
4. Pulpotomy (pharmacotherapeutic)
a. Inductive
Procedure: The objective of the inductive pharmacotherapeutic pulpotomy is to amputate infected or affected coronal pulp tissue and to treat the exposed radicular tissue in such a way as to induce (promote biologically) reparative dentin and preserve the vitality and function of the majority of the remaining radicular pulp.
Objectives:
· The procedure is intended to conserve the vital tissue in the canals.
· The objective is to avoid future adverse clinical signs and symptoms.
· There should be no internal resorption or other pathology as determined by periodic radiographic evaluation.
b. Non-inductive
Procedure: The objective of a non-inductive pharmacotherapeutic approach to a pulpotomy is to amputate infected or affected coronal pulp tissue and to treat the remaining radicular pulp tissue with a medication or fixative agent that has as its purpose the elimination or neutralization of residual infectious processes.
Objectives:
· The procedure is intended to eliminate or neutralize the effects of pulp involvement by caries or trauma.
· The objective is to avoid future adverse clinical signs and symptoms.
· There should be no internal resorption or other pathology as determined by periodic radiographic evaluation.
· There should be no breakdown or periradicular supporting tissue.
5. Pulpotomy (non-pharmacotherapeutic)
Procedure: The objective of a non-pharmacotherapeutic approach to a pulpotomy is to amputate infected or affected coronal pulp tissue and treat the remaining radicular pulp tissue by an electrical or laser energy form in such a way as to eliminate or neutralize residual infectious processes.
Objectives:
· The procedure is intended to eliminate or neutralize the effects of pulp involvement by caries or trauma.
· The objective is to avoid future adverse clinical signs and symptoms.
· There should be no internal resorption or other pathology as determined by periodic radiographic evaluation.
· There should be no breakdown of periradicular supporting tissue.
B. Non-vital Pulp Therapy
1. Pulpectomy
Procedure: A pulpectomy is endodontic therapy for pulpally involved primary teeth that are untreatable by the standard pulpotomy. The objective of a pulpectomy is to eliminate pulpal and periradicular disease. Debridement, enlargement, and disinfection of all canals are to be performed under a rubber dam. The entire roof of the pulp chamber must be removed in order to gain proper access to the canals. (in some cases, more aggressive treatment might be attempted to prolong the life of an abscessed primary tooth when its retention is deemed critically important for occlusal integrity. Such a protocol might involve a two-stage treatment where a cotton pellet of disinfectant is sealed in the pulp chamber following coronal amputation. Additionally, abscessed tissue might be curetted from the furcation area. If necessary, a small elliptical-shaped piece of mucosa can be incised and removed to ensure access and drainage. One week later the root canals are cleaned and the floor of the chamber is lightly moistened with a suitable disinfectant.) The canals of all pulpectomized primary teeth should be filled with resorbable material. The chamber is then filled and the tooth restored.
Objectives:
· The objective is to remove as much of the necrotic pulp as is feasible in the context of the succedaneous tooth and architecture of the remaining roots.· The procedure is intended to reverse the infectious process and permit any involved periradicular tissue to heal.
· The procedure should provide radiographic evidence of a successful three-dimensional filling without gross overentension or underfilling in the presences of a patent canal.
· There should be no adverse clinical signs or symptoms
· There should be no further breakdown of supporting tissues.
· Resorption of root structures and filling materials should occur at the appropriate age when a successor tooth is present.
2. ExtractionWhen the infectious process cannot be arrested, the bony support cannot be regained, remaining root structure will not support a crown, or inadequate tooth structure remains for a cost effective restoration, the primary tooth should be removed.
IV. PERMANENT TEETH
A. Vital Pulp Therapy
1. Protective Base
Procedure: An appropriate material is placed at the base of a preparation to act as a protective barrier to minimize further injury and permit the pulp tissue to heal.
Objectives:
· A radiopaque base should be placed between the permanent restoration and the dentin.
· The procedure is performed to prevent adverse clinical signs and symptoms.
· The procedure is performed to preserve the health and vitality of the restored tooth.
2. Indirect Pulp Treatment
Procedure: In a tooth with a deep carious lesion, complete removal of affected dentin is delayed, and the decay process is sealed with an appropriate restorative material. The purpose is to protect the pulp against further injury and to allow reparative dentin formation.
Objectives:
· A radiopaque base should be placed over the remaining affected dentin, but not in contact with the pulp tissue.
· The purpose of the procedure is to permit pulp healing and reparative dentin formation.
· It is the objective of the procedure to prevent adverse clinical signs and symptoms.
· The procedure is intended to avoid internal resorption of abnormal calcification as determined by periodic radiographic evaluation.
3. Direct Pulp Capping
Procedure: Direct pulp capping is indicated in two situation. In a permanent tooth that had a carious lesion near or into the pulp, a protective dressing or cement is placed directly over the vital pulp at the site of exposure to protect the pulp and stimulate reparative dentin formation. This procedure is also particularly valid for mechanical or traumatic exposures in permanent teeth when conditions favor a positive response.
Objectives:
· A radiopaque base should be placed in contact with the exposed pulp tissue.
· The objective of the base is to permit healing and reparative dentin formation.
· The purpose is to prevent further pulp damage and to avoid adverse clinical signs and symptoms.
· The procedure is intended to avoid internal resorption of abnormal calcification as determined by periodic radiographic evaluation.
4. Pulpotomy (Pharmacotherapeutic)
a. Inductive
Procedure: The objective of this kind of pulpotomy procedure is to amputate infected or affected coronal pulp tissue and to treat the exposed radicular tissue in such a way as to induce (promote biologically) reparative dentin and to preserve the vitality and function of the majority of the remaining radicular pulp.
Objectives:
· The procedure is intended to conserve the maximum vital tissue in the canals.
· The objective is to avoid future adverse clinical signs and symptoms.
· There should be no internal resorption or abnormal canal calcification as determined by periodic radiographic evaluation.
· There should be no breakdown of periradicular supporting tissue.
b. Non-inductive
Procedure: The objective of a non-inductive pharmacotherapeutic approach to a pulpotomy is to amputate infected or affected coronal pulp tissue and to treat the remaining radicular pulp tissue with a medication or fixative agent which has as its purpose the elimination or neutralization of residual infectious processes. At this time, non-inductive agents are recommended for treatment of permanent teeth only when time constraints or economic reasons prevent appropriate root canal therapy.
Objectives:
· The procedure is intended to neutralize the effects of pulp involvement by caries or trauma.
· The objective is to avoid future adverse clinical signs and symptoms.
· There should be no internal resorption or other pathology as determined by periodic radiographic evaluation.
· There should be no breakdown of periradicular supporting tissue.
5. Pulpotomy (non-pharmacotherapeutic)Procedure: The objective of a non-pharmacotherapeutic approach to a pulpotomy is to amputate infected or affected coronal pulp tissue and to treat the remaining radicular pulp tissue with an electrical or laser energy form which has as its purpose the elimination of residual infectious processes. At this time, this form of therapy is recommended for treatment of permanent teeth only when time constraints or economic reasons prevent root canal therapy.
Objectives:· The procedure is intended to eliminate or neutralize the effects of pulp involvement by caries or trauma.
· The objective is to avoid future adverse clinical signs and symptoms.· There should be no internal resorption or other pathology as determined by periodic radiographic evaluation.
· There should be no breakdown of periradicular supporting tissue.
6. Root Formation (Apexogenesis)
Procedure: This procedure involves surgical amputation of the coronal portion of vital pulp and the treatment with an agent which will preserve the vitality of the radicular tissue. This is an interim procedure to encourage root formation (Apexogenesis) of teeth with immature root development or as an emergency procedure until root canal treatment can be accomplished.
Objectives:
· The procedure is intended to provide for radiographic evidence of canal and root apex closure, sometimes accompanied by an increase in root length.
· The objective is to prevent adverse clinical signs and symptoms.
· There should be no abnormal canal calcification or internal resorption as determined by periodic radiographic evaluation.
· There should be no breakdown of the periradicular supporting tissue.
B. Non-vital Pulp Therapy
1. Apexification
Procedure: Apexification is a method of inducing apical closure of the root or roots of an incompletely formed permanent tooth when normal Apexogenesis has been jeopardized by necrosis of the pulp tissue. The procedure involves removal of the necrotic tissue short of the sites of potential apexification, and the placement of calcium hydroxide or other suitable agents in the canals. Several treatments may be necessary. When closure is observed radiographically, endodontic therapy must be performed.
Objectives:
· The procedure is intended to induce apexification--if not apexogenesis--at the apices of immature roots with necrotic pulp tissue.
· There should be no further adverse clinical signs or symptoms.
· The procedure should provide radiographic evidence of apical closure without breakdown of the supporting tissues.
· There should be no lateral root pathosis during therapy.
2. Pulpectomy (root canal therapy)
Procedure: Pulpectomy in permanent teeth is endodontic therapy for infected and/or necrotic teeth in order to eliminate pulpal and periradicular disease. Debridement, enlargement, and disinfection of all canals are to be performed under a rubber dam. In all cases, the entire roof of the pulp chamber must be removed in order to gain proper access to the canals.
Obturation of the canals should be accomplished with a non-resorbable filling material.
Objectives:
· The objective is to remove as much of the necrotic pulp as is feasible in the context of the status of the tooth and the architecture of the roots.
· The procedure should provide radiographic evidence of a successful three-dimensional filling without gross overextension or underfilling in the presence of a patent canal.
· There should be no adverse clinical signs or symptoms.
· There should be no further breakdown of supporting tissues.
3. Extraction
When the infectious process cannot be arrested, the bony support cannot be regained, remaining root structure will not support a crown, or inadequate tooth structure remains for a cost effective restoration, the permanent tooth should be removed.