Vital Pulp Therapy for

the Primary Dentition Indirect Pulp Treatment vs. Pulpotomy

Brian Talley, DMD

Halley White Pediatric Dentistry, P.A.

Wilmington, NC

Vital Pulp Therapy1 in the primary dentition

• No pulpitis

• Healthy tooth with trauma

• Reversible pulpitis - exhibiting provoked pain of short duration, that is relieved upon the removal of stimulus, with analgesics or by brushing

• Pulp is judged by clinical and radiographic criteria to be vital and able to heal from the carious or traumatic insult

Non-Vital Pulp Therapy in the primary dentition

• Hx of spontaneous, unprovoked pain

• Sinus tract

• Periodontal inflammation not resulting from gingivitis or periodontitis

• Excessive mobility not associated with trauma or exfoliation

• Furcation/apical radiolucency

• Radiographic evidence of internal/external resorption

Indirect Pulp Treatment1

• Tooth with deep carious lesion adjacent to the pulp

• Caries near the pulp is left to avoid pulp exposure

• Caries covered with a biocompatible material

• Calcium hydroxide, zinc oxide and eugenol, or glass ionomer cement is placed over the remaining affected dentin to stimulate healing and repair

• Tooth restored with a material that seals the tooth from microleakage

Indirect Pulp Treatment

Pulpotomy1 • Tooth with a deep carious

lesion adjacent to the pulp

• Caries removal results in pulp exposure

• Coronal pulp is amputated

• Remaining vital radicular pulp tissue surface treated with a medicament (formocresol, ferric sulfate, MTA or cauterized with electrosurgery or laser)

• Coronal pulp chamber is filled with a suitable base

• Tooth is restored with a restoration that seals the tooth from microleakage

What’s Being Taught and

being Used in Pediatric

Programs in US Dental

Schools

&

by ABPD Diplomates?

Survey Results Regarding Teaching and Use of

Indirect Pulp Therapy (IPT) in Primary Teeth2

Directors

1997

Directors

2005

ABPD

Diplomates 2005

Teach or

use IPT 37/53 (70%) 40/48 (83%) 486/689 (71%)

IPT Liner Ca(OH)2: 33/37 (89%)

ZOE: 8/37 (22%)

GI: 6/47 (13%)

Ca(OH)2: 26/56 (47%)

ZOE: 4/56 (7%)

GI: 26/56 (47%)

Ca(OH)2: 323/644 (50%)

ZOE: 50/644 (8%)

GI: 271/644 (42%)

Don’t

re-enter

IPT

21/37 (57%) 40/45 (89%) 472/559 (84%)

Survey Results Regarding Teaching and Use of

Pulpotomy in Primary Teeth2

Directors

in 1997

Directors

in 2005

ABPD

Diplomates in

2005

Teach or

Use

Pulpotomy 53/53 (100%) 48/48 (100%) 681/689 (99%)

Pulpotomy

Medicants

1:5: Formo: 38/53 (72%)

100% Formo: 12/53 (22%)

Ferric sulfate: 2/53 (4%)

Other: 1/53 (2%)

1:5 Formo: 29/54 (54%)

100% Formo: 12/54 (22%)

Ferric sulfate: 13/54 (24%)

Other: 0

1:5 Formo: 345/702 (49%)

100% Formo: 223/702 (32%)

Ferric sulfate: 125/702 (18%)

Other: 9/702 (1%)

Success Rates -

Indirect Pulp Treatment

Reference IPT Material Success (%) Time

Buyukgural et al 20083 Various 100% 24 mo

Maltz et al 20074 Ca(OH)2 (dycal) 88% 36-45 mo

Vij et al 20045 GIC 94% 36 mo

Al-Zayer et al 20036 Ca(OH)2 (dycal) 95% 2 wks - 73 mo

Falster et al 20027 Various 90% 24 mo

Farooq et al. 20008 GIC 93% 24-90 mo

Success Rates -

Pulpotomy

References Pulpotomy Type Success (%) Time

Holan et al 20059 MTA 91% 38 mo

Vij et al 20045 100% Formocresol 70% 36 mo

Casas et al 200410 Ferric Sulfate 67% 36 mo

Eidelman et al 200111 MTA 100% 13 mo

Farooq et al 20008 100% Formocresol 74% 24-84 mo

Smith et al 200012 Ferric Sulfate 74-80% 19 mo

Gruythuysen et al 199713 Ca(OH)2 80% 24 mo

Fuks et al 199714 1:5 Formo/FeS 84% Formo, 93%FeS 6 mo

Caries Control and Other Variables Associated

With Success of Primary Molar Vital Pulp

Therapy Vij R, Coll J, Shelton P, Farooq N.

Pediatric Dentistry 2003; 26(3) 214-220.

• Methods: Restrospective chart audits on 226 primary molars with deep caries treated with IPT and FP

• Results:

– IPT was successful 94% of the time, whereas FP was successful 70% of the time

– Primary molar FP success on primary 1st molars was 61% vs 83% in the 2nd molars

– IPT was successful 92% of the time for 1st molars vs 98% of the time for 2nd molars

– 36% of FP treated teeth exfoliated early vs 2% of IPT treated teeth

– Type of final restoration did not affect IPT or FP success

Success rates of formocresol pulpotomy and

indirect pulp therapy in the treatment of deep

dentinal caries in the primary teeth Farooq N, Coll J, Kuwabara A, Shelton P. Pediatric Dentistry 2000; (20)4:

278-286.

• Methods:133 primary molars with deep caries approaching

the pulp were treated with FP or IPT and followed 2-7 years.

• Results:

– Overall IPT success was 93% vs 74% for FP

– FP treated molars exhibited earlier exfoliation 38%, while all

IPT molars exhibited normal exfoliation

– Molars with pain compatible with a diagnosis of reversible

pulpitis were successfully treated by IPT 85% vs 76% for FP

What are dentists doing?

• 70% of surveyed program directors and

80% of surveyed pediatric dentists

reported that a pulpotomy is the

treatment of choice over IPT2

And…

• When given a scenario for a tooth that

had the indications for IPT, according to

the AAPD guidelines, only 30% of

directors and 19% of the diplomates

performed an IPT2

What Research Shows • IPT has been shown to have a lower cost,

higher success long-term, better exfoliation pattern, and a better success treating reversible pulpitis than pulpotomy

• At a symposium with pediatric dentists and endodontists, more than half stated they would stop caries excavation and perform an IPT rather than a pulpotomy, and 75% agree that there is evidence that IPT is as successful as pulpotomy in primary teeth15

Indirect Pulp

Therapy

Pre-op

10/8/07

16 months

Post-op

03/25/09

#L

Indirect Pulp Treatment

#S & #T

Pre-op

Immediate

Post-op 6 months

12 months 18 months 24 months

Indirect Pulp Treatment #K

Pre-op

Immediate

Post-op 6 months

12 months 18 months 24 months

Questions?

References 1. American Academy of Pediatric Dentistry. Guideline on pup therapy for

primary and young permanent teeth. AAPD Reference Manuel 2008/2009;

30(7): 170-174.

2. Dunston B, Coll J. A survey of primary tooth pulp therapy as taught in US

dental schools and practiced by diplomates of the American Board of

Pediatric Dentistry. Pediatric Dentistry 2008; 30(1): 42-48.

3. Buyukgural B, Cehreli Z. Effect of different adhesive protocols vs calcium

hydroxide on primary tooth pulp with different remaining dentin thickness: 24-

month results. Clinical Oral Investigations 2008; 12: 91-96.

4. Maltz M, Oliveira E, Fontanella V, Carminatti G. Deep caries lesions after

incomplete detine cares removal: 40-month follow-up study. Caries Research

2007; 41: 493-496.

5. Vij R, Coll J, Shelton P, Farooq N. Caries control and other variables

associated with success of primary molar vital pulp therapy. Pediatric

Dentistry 2004; 26(3): 214-220

6. Al-Zayer M, Straffon L, Feigal R, Welch K. Indirect pulp treatment of primary

posterior teeth: a restrospective study. Peditric Dentistry 2003; 25(1): 29-36.

References 7. Falster C, Araujo F, Straffon L, Nor J. Indirect pulp treatment: in vivo

outcomes of an adhesive resin system vs calcium hydroxide for protection of

the dentin-pulp complex. Pediatric Dentistry 2002; 24(3): 241-248.

8. Farooq N, Coll J, Kuwabara A, Shelton P. Success rates of formocresol

pulpotomy and indirect pulp therapy in the treatment of deep dentinal caries

in primary teeth. Pediatric Dentistry 2000; 22(4): 278-286.

9. Holan G, Eidelman E, Fuks A. Long-term evaluation of pulpotomy in primary

molars using mineral trioxide aggregate or formocresol. Pediatric Dentistry

2005; 27(2): 129-136.

10. Casas M, Kenny D, Johnston D, Judd P. Long-term outcomes of primary

molar ferric sulfate pulpotomy and root canal therapy. Pediatric Dentistry

2004; 26(1): 44-48

11. Eidelman E, Holan G, Fuks A. Mineral trioxide aggregate vs. formocresol in

pulpotomized primary molars: a preliminary report. Pediatric Dentistry 2001;

23(1): 15-18.

12. Smith N, Seale N, Nunn M. Ferric sulfate pulpotomy in primary molars: a

retrospective study. Pediatric Dentistry 2000; 22(3): 192-199.

References 13. Gruythuysen R, Weerheijm K. Calcium hydroxide pulpotomy with a light-cured

cavity sealing material after two years. ASDC J Dent Child 1997; 64(4): 251-

253.

14. Fuks A, Holan G, Davis J, Eidelman E. Ferric sulfate versus dilute formocresol

in pulpotomized primary molars: long-term follow up. Pediatric Dentistry 1997;

19(5): 327-330.

15. Seale N, Glickman G. Contemporary perspectives on vital pulp therapy: views

from the endodontists and pediatric dentists. Pediatric Dentistry 2008; 30(3):

261-267.