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reference manual v 32 / no 6 10 / 11

Guideline on Pulp Therapy for Primary and


Immature Permanent Teeth
Originating Committee
Clinical Affairs Committee Pulp Therapy Subcommittee
Review Council
Council on Clinical Affairs

Adopted
1991

Revised
1998, 2001, 2004, 2009

Purpose treatment of the young permanent dentition. A tooth without a


The American Academy of Pediatric Dentistry (AAPD) intends vital pulp, however, can remain clinically functional.1
this guideline to aid in the diagnosis of pulp health versus The indications, objectives, and type of pulpal therapy
pathosis and to set forth the indications, objectives, and thera- depend on whether the pulp is vital or nonvital, based on the
peutic interventions for pulp therapy in primary and imma- clinical diagnosis of normal pulp (symptom free and normally
ture permanent teeth. responsive to vitality testing), reversible pulpitis (pulp is capable
of healing), symptomatic or asymptomatic irreversible pulpitis
Methods (vital inflamed pulp is incapable of healing), or necrotic pulp.2
This revision included a new systematic literature search of The clinical diagnosis3 is derived from a:
the MEDLINE/Pubmed electronic data base using the follow- 1. comprehensive medical history;
ing parameters: Terms: pulpotomy, pulpectomy, indirect 2. review of past and present dental history and treatment,
pulp treatment, stepwise excavation, pulp therapy, pulp including current symptoms and chief complaint;
capping, pulp exposure, bases, liners, calcium hydroxide, 3. subjective evaluation of the area associated with the
formocresol, ferric sulfate, gluteraldehyde pulpotomies, current symptoms/chief complaint by questioning the
glass ionomer, mineral trioxide aggregate (MTA), bacterial child and parent on the location, intensity, duration,
microleakage under restorations, dentin bonding agents, stimulus, relief, and spontaneity;
resin modifies glass ionomers (RMGIs), and endodontic 4. objective extraoral examination as well as examination
irrigants; Fields: all fields, Limits: within the last 10 years, of the intraoral soft and hard tissues;
humans, English, and clinical trials. Papers for review were 5. if obtainable, radiograph(s) to diagnose pulpitis or ne-
chosen from the resultant lists and from hand searches. crosis showing the involved tooth, furcation, periapical
When data did not appear sufficient or were inconclusive, area, and the surrounding bone; and
recommendations were based upon expert and/or consensus 6. clinical tests such as palpation, percussion, and
opinion including those from the 2007 joint symposium of mobility.1,4
the AAPD and the American Association of Endodontists In permanent teeth, electric pulp tests and thermal tests
(AAE) titled Emerging Science in Pulp Therapy: New Insights may be helpful.3 Teeth exhibiting signs and/or symptoms such
into Dilemmas and Controversies (Chicago, Ill). as a history of spontaneous unprovoked toothache, a sinus
tract, soft tissue inflammation not resulting from gingivitis or
Background periodontitis, excessive mobility not associated with trauma or
The primary objective of pulp therapy is to maintain the integ- exfoliation, furcation/apical radiolucency, or radiographic evi-
rity and health of the teeth and their supporting tissues. It is a dence of internal/external resorption have a clinical diagnosis
treatment objective to maintain the vitality of the pulp of a tooth of irreversible pulpitis or necrosis. These teeth are candidates
affected by caries, traumatic injury, or other causes. Especially in for nonvital pulp treatment.5,6
young permanent teeth with immature roots, the pulp is integral Teeth exhibiting provoked pain of short duration relieved
to continue apexogenesis. Long term retention of a perma- with over-the-counter analgesics, by brushing, or upon the
nent tooth requires a root with a favorable crown/root ratio removal of the stimulus and without signs or symptoms of
and dentinal walls that are thick enough to withstand normal irreversible pulpitis, have a clinical diagnosis of reversible
function. Therefore, pulp preservation is a primary goal for pulpitis and are candidates for vital pulp therapy. Teeth diag-

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nosed with a normal pulp requiring pulp therapy or with re- Primary teeth
versible pulpitis should be treated with vital pulp procedures.7-10 Vital pulp therapy for primary teeth diagnosed with a
normal pulp or reversible pulpitis
Recommendations Protective liner
All relevant diagnostic information, treatment, and treatment A protective liner is a thinly-applied liquid placed on the pulpal
follow-up shall be documented in the patients record. surface of a deep cavity preparation, covering exposed dentin
Any planned treatment should include consideration of: tubules, to act as a protective barrier between the restorative
1. the patients medical history; material or cement and the pulp. Placement of a thin protective
2. the value of each involved tooth in relation to the liner such as calcium hydroxide, dentin bonding agent, or glass
childs overall development; ionomer cement is at the discretion of the clinician.13,14
3. alternatives to pulp treatment; and Indications: In a tooth with a normal pulp, when all caries
4. restorability of the tooth. is removed for a restoration, a protective liner may be placed
When the infectious process cannot be arrested by the treat- in the deep areas of the preparation to minimize injury to the
ment methods included in this section, bony support cannot be pulp, promote pulp tissue healing, and/or minimize postopera-
regained, inadequate tooth structure remains for a restoration, or tive sensitivity.15,16
excessive pathologic root resorption exists, extraction should be Objectives: The placement of a liner in a deep area of the
considered.1,5,6 preparation is utilized to preserve the tooths vitality, promote
It is recommended that all pulp therapy be performed with pulp tissue healing and tertiary dentin formation, and mini-
rubber-dam or other equally effective isolation to minimize mize bacterial microleakage.17,18 Adverse post-treatment clinical
bacterial contamination of the treatment site. signs or symptoms such as sensitivity, pain, or swelling should
This guideline is intended to recommend the best not occur.
currently-available clinical care for pulp treatment, but the
AAPD encourages additional research for consistently success- Indirect pulp treatment
ful and predictable techniques using biologically-compatible Indirect pulp treatment is a procedure performed in a tooth with
medicaments for vital and nonvital primary and immature a deep carious lesion approximating the pulp but without signs
permanent teeth. Pulp therapy requires periodic clinical and or symptoms of pulp degeneration.1 The caries surrounding
radiographic assessment of the treated tooth and the supporting the pulp is left in place to avoid pulp exposure and is covered
structures. Post-operative clinical assessment generally should be with a biocompatible material.19 A radiopaque liner such as
performed every 6 months and could occur as part of a patients a dentin bonding agent,20 resin modified glass ionomer,21,22
periodic comprehensive oral examinations. Patients treated for calcium hydroxide,23,24 zinc oxide/eugenol,24 or glass ionomer
an acute dental infection initially may require more frequent cement7,9,25-27 is placed over the remaining carious dentin to
clinical reevaluation. A radiograph of a primary tooth pulpec- stimulate healing and repair. If calcium hydroxide is use, a glass
tomy should be obtained immediately following the procedure ionomer or reinforced zinc oxide/eugenol material should be
to document the quality of the fill and to help determine the placed over it to provide a seal against microleakage since calcium
tooths prognosis. This image also would serve as a comparative hydroxide has a high solubility, poor seal, and low compressive
baseline for future films (the type and frequency of which are at strength.28-31 The use of glass ionomer cements or reinforced zinc
the clinicians discretion). Radiographic evaluation of primary oxide/eugenol restorative materials has the additional advan-
tooth pulpotomies should occur at least annually because the tage of inhibitory activity against cariogenic bacteria.32,33 The
success rate of pulpotomies diminishes over time.11 Since failure tooth then is restored with a material that seals the tooth from
of a primary molar pulpotomy may be evidenced in the furca- microleakage. Interim therapeutic restorations (ITR) with glass
tion, posterior tooth pulpotomies should be monitored by ionomers can used for caries control in teeth with carious lesions
radiographs that clearly demonstrate the interradicular area. that exhibit signs of reversible pulpitis. The ITR can be removed
Bitewing radiographs obtained as part of the patients periodic once the pulps vitality is determined and, if the pulp is vital,
comprehensive examinations may suffice. If a bitewing radio- an indirect pulp cap can be performed.34,35 Current literature
graph does not display the interradicular area, a periapical image indicates that there is inconclusive evidence that it is necessary
is indicated. Pulp therapy for immature permanent teeth should to reenter the tooth to remove the residual caries.36,37 As long
be reevaluate radiographically 6 and 12 months after treatment as the tooth remains sealed from bacterial contamination, the
and then periodically at the discretion of the clinician. For any prognosis is good for caries to arrest and reparative dentin to
tooth that has undergone pulpal therapy, clinical signs and/or form to protect the pulp.32,33,36-40 Indirect pulp capping has
symptoms may prompt a clinician to select a more frequent been shown to have a higher success rate than pulpotomy in
periodicity of reassessment. long term studies.7,9,20,22-27,35 It also allows for a normal exfolia-
Apexification, reimplantation of avulsions, and placement tion time. Therefore, indirect pulp treatment is preferable to
of prefabricated post and cores are not indicated for primary a pulpotomy when the pulp is normal or has a diagnosis of
teeth. For endodontic procedures not included in this section, reversible pulpitis.
the AAPD supports the AAEs Guide to Clinical Endodontics.12

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reference manual v 32 / no 6 10 / 11

Indications: Indirect pulp treatment is indicated in a primary Indications: The pulpotomy procedure is indicated when
tooth with no pulpitis18 or with reversible pulpitis when the caries removal results in pulp exposure in a primary tooth with
deepest carious dentin is not removed to avoid a pulp exposure.8 a normal pulp or reversible pulpitis or after a traumatic pulp
The pulp is judged by clinical and radiographic criteria to be exposure.6 The coronal tissue is amputated, and the remain-
vital and able to heal from the carious insult.8,9 ing radicular tissue is judged to be vital without suppuration,
Objectives: The restorative material should seal completely the purulence, necrosis, or excessive hemorrhage that cannot be
involved dentin from the oral environment. The tooths vital- controlled by a damp cotton pellet after several minutes, and
ity should be preserved. No post-treatment signs or symptoms there are no radiographic signs of infection or pathologic re-
such as sensitivity, pain, or swelling should be evident. There sorption.
should be no radiographic evidence of pathologic external or Objectives: The radicular pulp should remain asymptomatic
internal root resorption or other pathologic changes. There without adverse clinical signs or symptoms such as sensitivity,
should be no harm to the succedaneous tooth. pain, or swelling. There should be no postoperative radiogra-
phic evidence of pathologic external root resorption. Internal
Direct pulp cap root resorption can be self limiting and stable. The clinician
When a pinpoint mechanical exposure of the pulp is encoun- should monitor the internal resorption, removing the affected
tered during cavity preparation or following a traumatic in- tooth if perforation causes loss of supportive bone and/or
jury, a biocompatible radiopaque base such as mineral trioxide clinical signs of infection and inflammation.52,55,66-68 There
aggregate (MTA)41-44 or calcium hydroxide45 may be placed in should be no harm to the succedaneous tooth.
contact with the exposed pulp tissue. The tooth is restored
with a material that seals the tooth from microleakage.7 Nonvital pulp treatment for primary teeth diagnosed with
Indications: This procedure is indicated in a primary tooth irreversible pulpitis or necrotic pulp
with a normal pulp following a small mechanical or traumatic Pulpectomy
exposure when conditions for a favorable response are opti- Pulpectomy is a root canal procedure for pulp tissue that is ir-
mal.41-45 Direct pulp capping of a carious pulp exposure in a reversibly infected or necrotic due to caries or trauma. The root
primary tooth is not recommended.1 canals are debrided and shaped with hand or rotary files. 21
Objectives: The tooths vitality should be maintained. No Since instrumentation and irrigation with an inert solution
post-treatment signs or symptoms such as sensitivity, pain, or alone cannot adequately reduce the microbial population
swelling should be evident. Pulp healing and reparative dentin in a root canal system, disinfection with irrigants such as 1%
formation should result. There should be no radiographic signs sodium hypochlorite and/or chlorhexidine is an important step
of pathologic external or progressive internal root resorption in assuring optimal bacterial decontamination of the canals.68-70
or furcation/apical radiolucency. There should be no harm to Because it is a potent tissue irritant, sodium hypochlorite must
the succedaneous tooth. not be extruded beyond the apex.71 After the canals are dried, a
resorbable material such as nonreinforced zinc/oxideeugenol,5,72
Pulpotomy iodoform-based paste (KRI),73 or a combination paste of
A pulpotomy is performed in a primary tooth with extensive iodoform and calcium hydroxide (Vitapex, Endoflax)74-76 is
caries but without evidence of radicular pathology when caries used to fill the canals. The tooth then is restored with a restora-
removal results in a carious or mechanical pulp exposure. The tion that seals the tooth from microleakage.
coronal pulp is amputated, and the remaining vital radicular Indications: A pulpectomy is indicated in a primary tooth
pulp tissue surface is treated with a long-term clinically- with irreversible pulpitis or necrosis or a tooth treatment plan-
successful medicament such as Buckleys Solution of formo- ned for pulpotomy in which the radicular pulp exhibits clinical
cresol or ferric sulfate.46-52 Electrosurgery also has demonstrated signs of irreversible pulpitis (eg, excessive hemorrhage that is
success.53 Gluteraldehyde54,55 and calcium hydroxide50,52,56 have not controlled with a damp cotton pellet applied for several
been used but with less long-term success. MTA is a more minutes) or pulp necrosis (eg, suppration, purulence). The roots
recent material used for pulpotomies with a high rate of should exhibit minimal or no resorption.
success. Clinical trials show that MTA performs equal to or Objectives: Following treatment, the radiographic infectious
better than formocresol or ferric sulfate8,11,57-61 and may be the process should resolve in 6 months, as evidenced by bone
preferred pulpotomy agent in the future.61,62 After the coronal deposition in the pretreatment radiolucent areas, and pretreat-
pulp chamber is filled with zinc/oxide eugenol or other suit- ment clinical signs and symptoms should resolve within a few
able base, the tooth is restored with a restoration that seals the weeks. There should be radiographic evidence of successful
tooth from microleakage. The most effective long-term restora- filling without gross overextension or underfilling.72,74,76 The
tion has been shown to be a stainless steel crown. However, if treatment should permit resorption of the primary tooth root
there is sufficient supporting enamel remaining, amalgam or and filling material to permit normal eruption of the succeda-
composite resin can provide a functional alternative when the neous tooth. There should be no pathologic root resorption or
primary tooth has a life span of 2 years or less.63-65 furcation/apical radiolucency.

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Young permanent teeth judged by clinical and radiographic criteria to be vital and able
Vital pulp therapy for teeth diagnosed with a normal pulp to heal from the carious insult.6
or reversible pulpitis Objectives: The intermediate and/or final restoration should
Protective liner seal completely the involved dentin from the oral environment.
A protective liner is a thinly-applied liquid placed on the pulpal The vitality of the tooth should be preserved. No post-treatment
surface of a deep cavity preparation, covering exposed dentin signs or symptoms such as sensitivity, pain, or swelling should be
tubules, to act as a protective barrier between the restorative evident. There should be no radiographic evidence of internal or
material or cement and the pulp. Placement of a thin protective external root resorption or other pathologic changes. Teeth with
liner such as calcium hydroxide, dentin bonding agent, or glass immature roots should show continued root development and
ionomer cement is at the discretion of the clinician.13,14 The liner apexogenesis.
must be followed by a well-sealed restoration to minimize bacte-
rial leakage from the restoration-dentin interface.17,18 Partial pulpotomy for carious exposures
Indications: In a tooth with a normal pulp, when caries is The partial pulpotomy for carious exposures is a procedure in
removed for a restoration, a protective liner may be placed in the which the inflamed pulp tissue beneath an exposure is removed
deep areas of the preparation to minimize pulp injury, promote to a depth of 1 to 3 mm or deeper to reach healthy pulp tissue.
pulp tissue healing, and/or minimize postoperative sensitivity. Pulpal bleeding must be controlled by irrigation with a bacte-
Objectives: The placement of a liner in a deep area of the riocidal agent such as sodium hypochlorite or chlorhexidine68-70
preparation is utilized to preserve the tooths vitality, promote before the site is covered with calcium hydroxide6,91,92 or MTA.93-
pulp tissue healing, and facilitate tertiary dentin formation. This 95
While calcium hydroxide has been demonstrated to have long-
liner must be followed by a well-sealed restoration to minimize term success, MTA results in more predictable dentin bridging
bacterial leakage from the restoration-dentin interface.17,18 and pulp health.96 MTA (at least 1.5 mm thick) should cover
Adverse post-treatment signs or symptoms such as sensitivity, the exposure and surrounding dentin followed by a layer of
pain, or swelling should not occur. light cured resin-modified glass ionomer.90 A restoration that
seals the tooth from microleakage is placed.
Indirect pulp treatment Indications: A partial pulpotomy is indicated in a young
Indirect pulp treatment is a procedure performed in a tooth permanent tooth for a carious pulp exposure in which the pulpal
with a diagnosis of reversible pulpitis and deep caries that might bleeding is controlled within several minutes. The tooth must
otherwise need endodontic therapy if the decay was completely be vital, with a diagnosis of normal pulp or reversible pulpitis.6
removed.6 In recent years, rather than complete the caries remov- Objectives: The remaining pulp should continue to be vital
al in 2 appointments, the focus has been to excavate as close as after partial pulpotomy. There should be no adverse clinical
possible to the pulp, place a protective liner, and restore the tooth signs or symptoms such as sensitivity, pain, or swelling. There
without a subsequent reentry to remove any remaining affected should be no radiographic sign of internal or external resorp-
dentin.77-79 The risk of this approach is either an unintentional tion, abnormal canal calcification, or periapical radiolucency
pulp exposure or irreversible pulpitis.78 More recently, the step- postoperatively. Teeth having immature roots should continue
wise excavation of deep caries has been revisited70-82 and shown normal root development and apexogenesis.
to be successful in managing reversible pulpitis without pulpal
perforation and/or endodontic therapy.83 This approach involves Partial pulpotomy for traumatic exposures (Cvek pulpotomy)
a 2-step process. The first step is the removal of carious dentin The partial pulpotomy for traumatic exposures is a procedure in
along the dentin-enamel junction (DEJ) and excavation of only which the inflamed pulp tissue beneath an exposure is removed
the outermost infected dentin, leaving a carious mass over the to a depth of 1 to 3 mm or more to reach the deeper healthy
pulp. The objective is to change the cariogenic environment in tissue. Pulpal bleeding is controlled using bacteriodical irri-
order to decrease the number of bacteria, close the remaining gants such as sodium hypochlorite or chlorhexidine69,70, and
caries from the biofilm of the oral cavity, and slow or arrest the the site then is covered with calcium hydroxide97-100 or
caries development.83-85 The second step is the removal of the MTA.6,101 White, rather than gray, MTA is recommended
remaining caries and placement of a final restoration. The most in anterior teeth to decrease the chance of discoloration. The
common recommendation for the interval between steps is 3-6 2 versions have been shown to have similar properties.102,103
months, allowing sufficient time for the formation of tertiary While calcium hydroxide has been demonstrated to have long-
dentin and a definitive pulpal diagnosis. Critical to both steps term success, MTA results in more predictable dentin brid-
of excavation is the placement of a well-sealed restoration.17,18 ging and pulp health.96 MTA (at least 1.5 mm thick) should
The decision to use a one-appointment caries excavation or a cover the exposure and surrounding dentin, followed by a
step-wise technique should be based on the individual patient layer of light-cured resin-modified glass ionomer.101 A resto-
circumstances since the research available is inconclusive on ration that seals the tooth from microleakage is placed.
which approach is the most successful over time.36,37 Indications: This pulpotomy is indicated for a vital,
Indications: Indirect pulp treatment is indicated in a perma- traumatically-exposed, young permanent tooth, especially
nent tooth diagnosed with a normal pulp with no symptoms of one with an incompletely formed apex. Pulpal bleeding after
pulpitis or with a diagnosis of reversible pulpitis. The pulp is removal of inflamed pulpal tissue must be controlled. Neither

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time between the accident and treatment nor size of exposure by MTA, an absorbable collagen wound dressing (eg, Colla-
is critical if the inflamed superficial pulp tissue is amputated to Cote)106 can be placed at the root end to allow MTA to be
healthy pulp.104 packed within the confines of the canal space. Gutta percha is
Objectives: The remaining pulp should continue to be vital used to fill the remaining canal space. If the canal walls are thin,
after partial pulpotomy. There should be no adverse clinical the canal space can be filled with MTA or composite resin in-
signs or symptoms of sensitivity, pain, or swelling. There should stead of gutta percha to strengthen the tooth against fracture.107
be no radiographic signs of internal or external resorption, Indications: This procedure is indicated for nonvital perma-
abnormal canal calcification, or periapical radiolucency post- nent teeth with incompletely formed roots.
operatively. Teeth with immature roots should show continued Objectives: This procedure should induce root end closure
normal root development and apexogenesis. (apexification) at the apices of immature roots or result in an
apical barrier as confirmed by clinical and radiographic evalu-
Apexogenesis (root formation) ation. Adverse post-treatment clinical signs or symptoms of
Apexogenesis is a histological term used to describe the contin- sensitivity, pain, or swelling should not be evident. There
ued physiologic development and formation of the roots apex. should be no radiographic evidence of external root resorption,
Formation of the apex in vital, young, permanent teeth can lateral root pathosis, root fracture, or breakdown of periradi-
be accomplished by implementing the appropriate vital pulp cular supporting tissues during or following therapy. The
therapy previously described in this section (ie, indirect pulp tooth should continue to erupt, and the alveolus should con-
treatment, direct pulp capping, partial pulpotomy for carious tinue to grow in conjunction with the adjacent teeth.
exposures and traumatic exposures).
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