Treatment of Teeth with Vital Pulp

The following treatments are prescribed for teeth with vital pulp:

Pulp capping
Direct pulp capping
Partial pulpotomy
Pulpotomy
Pulpectomy

Pulp capping

Pulp capping is traditionally divided into two different procedures: Indirect pulp capping and direct pulp capping.

Indirect pulp capping is a procedure in which the most pulpal part of the carious dentin in a deep cavity is not removed. A temporary filling is placed and the cavity is reopened after some months and the remaining carious dentin is then excavated. The goal for this treatment is to give the pulp a chance to form more dentin beneath the carious dentin so that a pulp exposure can be avoided. This kind of treatment is mainly used in young teeth. Indirect pulp capping is a temporary procedure and it is not permitted to leave carious dentin under a permanent restoration.

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Direct pulp capping

This treatment is indicated when a pulp, without inflammation, has been exposed. This means that this kind of treatment cannot be used after a carious exposure of a pulp. The prognosis for capping an inflamed pulp is very poor and therefore performing this treatment after a pulp exposure in a tooth with carious dentin is not justified.

1. Pulp capping must be carried out under aseptic conditions, using rubber dam.
2. The exposed pulp tissue is removed by means of a round high-speed diamond stone using sterile isotonic saline as irrigant and cooling agent. The wound surface is placed some mm into the pulp in order to reach a tissue capable of healing and to prevent leakage from the oral cavity.
3. The bleeding is stopped by irrigation with sterile, isotonic saline.
4. A paste of calcium hydroxide and water (or Dycal®) is placed on the exposed pulp.
5. Excess water is removed with cotton pellets.
6. The capping material is covered with a cement, (not zinc phosphate cement which cannot prevent microleakage).
7. The permanent filling is placed.
8. The tooth is to be checked radiographically and clinically for 4-5 years.

Direct pulp capping is mainly carried out in immature teeth to give the root a chance to develop: Apexogenesis. In the fully developed tooth a pulpectomy is preferred after a mechanical exposure. There are three main reasons for this:

1. the prognosis for pulpectomy treatment is superior to the prognosis for pulp capping.
2. the pulpectomy terminates in an area where a failure can easily be detected radiographically.
3. the hard tissue barrier under the pulp capping material is usually not solid, inclosures of soft tissue are common. Thus, future leakage under the permanent filling may bring bacteria into direct contact with the pulp.

Follow-up exam: 1 month, 3 months, 1 year and after that yearly. The procedure involves clinical examination, electric pulp testing, temperature test (cold) and radiograph.

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Partial pulpotomy

The indications for this treatment are the same as for direct pulp capping.

1. The treatment is carried out under aseptic conditions using a rubber dam.
2. The exposure is widened with a high speed diamond under constant water cooling to a depth of 1.5-2 mm.
3. The wound is irrigated with isotonic saline until bleeding has stopped. Note: it is imperative to avoid an "extra pulpal " blood clot. The presence of a blood clot will mean that the wound dressing (calcium hydroxide) will be placed on the clot and not on the pulp tissue.
4. A paste of calcium hydroxide and water is placed on the exposed pulp tissue. Excess water is removed by means of sterile cotton pellets.
5. The wound dressing is covered with a sealing cement.
6. The permanent filling is placed.
7. The tooth should be followed clinically and radiographically for 4-5 years.

Partial pulpotomy is mainly carried out in immature teeth to give the root a chance to develop: Apexogenesis. In the fully developed tooth a pulpectomy is preferred. There reasons for this are the same as for direct pulp capping. It has recently been shown that partial pulpotomy has a high success rate in fully developed young teeth. It has also been shown that this form of treatment will yield a continuous hard tissue barrier which is essential for the long term prognosis as restorations may leak. The outcome for partial pulpotomy is better than the outcome for direct pulp capping. Therefore, partial pulpotomy is the preferred treatment when there is a choice between pulp capping and partial pulpotomy.

Follow-up exam: 1 month, 3 months, 1 year and after that yearly. The procedure involves clinical examination, electric pulp testing, temperature test (cold) and radiograph.

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Pulpotomy

Pulpotomy is done when an inflamed pulp is exposed and the tooth is not fully developed. The pulpotomy will give the root a chance to further develop: Apexogenesis.

1. Removal of caries, old fillings, access preparation.
2. Disinfect the operation field with an antiseptic.
3. Use a completely aseptic technique, using rubber dam.
4. Remove the coronal portion of the pulp.
5. Place the wound surface 1-2 mm into the root canal. This is done in the same way as in pulp capping by means of high-speed bur (round bur or round diamond) and sterile, isotonic saline irrigation.
6. A paste of calcium hydroxide and water is placed on the pulp wound.
7. Excess water is removed with cotton pellets.
8. The wound dressing and the floor of the cavity is covered with a cement, e.g., zinc oxide eugenol cement.
9. The permanent filling is placed.
10. The tooth is to be checked clinically and radiographically until root development is completed.

In pediatric endodontics another technique is sometimes used when the remaining pulp of a deciduous tooth is not considered free from inflammation. Formocresol, a necrotizing (mummification) agent is used as a wound dressing. This method is unique - necrotic tissue is intentionally left in the human body. However, proper endodontic treatment may be difficult to carry out in very young children. (Also, a nonresorbable root filling material will be left after the resorption of the deciduous tooth if for example gutta-percha is used.)

Follow-up exam: 1 month, 3 months, 1 year and after that yearly until the root is fully developed (and a pulpectomy and root filling can be carried out).

Pulpectomy

Pulpectomy is performed when there is a pulp exposure in a fully developed tooth.

1. Removal of caries, old fillings, etc. Temporary buildup if necessary.
2. Access preparation.
3. Disinfection of the operative field including rubber dam with an antiseptic.
4. The pulp wound should be placed just inside the apical foramen, ideally at the apical constriction. Statistically, in most instances one mm short of the apex is "just inside the foramen." In order to place the wound there and to avoid instrumentation through the apical foramen, a thin instrument is teased into the canal to a level that is estimated to be 1-2 mm shy of the radiographic apex. By means of a radiograph (working length x-ray) taken with this instrument in place, the pulpectomy level is decided, usually 1 mm short of the radiographic apex.
5. Cleaning and shaping of the root canal using copious amounts of irrigation solution.
6. When the cleaning and shaping is finished the canal is dried and filled with a paste of calcium hydroxide and sterile water (instead of sterile water an anesthetic solution, isotonic saline, or sodium hypochlorite solution can be used).
7. The canal can be filled during the next visit if there are no symptoms and no exudation.

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Treatment of Teeth with Necrotic/Non-Vital Pulp

This treatment is indicated in the case of a tooth with a necrotic pulp, with or without a periapical inflammation; or when a tooth has been previously root filled and has to be retreated.

1. Removal of caries, old fillings, etc. temporary buildup if necessary.
2. Access preparation.
3. Disinfection of the operative field and rubber dam with an antiseptic.
4. The access cavity is filled with a biocompatible antiseptic irrigant, e.g., sodium hypochlorite. A thin endodontic file is carefully moved to a level that is estimated to be 1-2 mm short of the radiographic apex.
5. By means of a radiograph (working length x-ray), taken with the instrument in the canal, the working length is decided.(Usually 1 mm short of the radiographic apex).
6. Cleaning of the canal is started with thin instruments to avoid pushing necrotic, infected material through the apical foramen.
7. Cleaning and shaping of the root canal using copious amounts of irrigation solution.
8. When the cleaning and shaping is finished, the canal is dried and filled with a calcium hydroxide paste.
9. The canal can be filled during the next visit if there are no symptoms, no exudate, and any fistula has healed.

If there are symptoms and/or exudate, and/or the presence of a fistula, continue the treatment. This is a sign of remaining infection. When a fistula is still present after 2-3 visits, try to find out if there is another reason for the remaining fistula - root fracture, necrotic neighboring tooth etc.

Apexification

When the root is not fully developed, an apexification procedure is carried out. After thorough cleaning of the root canal, the calcium hydroxide is left for longer periods of time to give the root development a chance to continue. The intracanal medicament is usually changed after one month. After that, it is left for at least 6 months when a radiographic check-up is done. Usually the canal is cleaned again at this time and the canal is refilled with calcium hydroxide. Next radiographic check is done after another 6 months. If periapical healing and a closure of the root canal have taken place, the permanent root filling can be carried out. If root closure has not taken place, the tooth is checked again after another 6 months. Usually, an apexification procedure will give the desired result. However, in a few cases the root development will not continue and the canal has to be root filled without an apical stop.

Note 1: Apexification is a long term treatment that requires good temporary fillings.

Note 2: It is the elimination of infection from the root canal and not the action of calcium hydroxide that will make it possible for the body to continue root development. ( It is possible to carry out an apexification procedure successfully without the use of calcium hydroxide. However, a temporary calcium hydroxide root filling is a good means to keep the canal clean and free from infection.)