Diagnostic aids for selection of the tooth for vital pulp
therapy:
History of pain:
Although history of presence or absence of pain may not be as reliable in
dental diagnosis in children as in permanent teeth because of:
 Children may be unable of communication about pain
 In case of pulpal necrosis, there is pulpal degeneration but no pain but
still it should be considered.
Dentist should distinguish between 2 types of pain:
Provoked pain
 Induced by stimulus (cold, hot, chemical)
 Disappear after removal of stimulus
 Indicates:
 Pulp is vital but having minimum reversible damage
 Protected by thin dentine layer
Spontaneous (unprovoked) pain
 Constant, throbbing pain that may keep patient awake at night
Indicates:
 Advanced pulp damage (irreversible) with no chance to maintain vitality.
Clinical examination:
 Soft tissue examination: Examine intra and extra oral tissues for:
 Swelling or abscess.
 Fistulous tract.
 Lymphadenopathy (tender & enlarged).
 Abscess or fistula → endo. Treatment or extraction.
Hard tissue examination: Visual examination
 Discoloration, loss of translucency → pulp degeneration
 Destruction of enamel and dentine due to caries or trauma
 Broken, missing restoration
 Size of pulpal exposure and amount of pulpal bleeding → which is a very
important valuable observation in decision of vital pulp therapy where if :
-vital pulp therapy → small, pin point, surrounded by sound dentine
-non-vital pulp therapy → large associated with watery exudates or pus.
 Palpitation
 Bony contour.
 Compare with contra-lateral .
 Mobility
 Causes of mobility:
 Normal exfoliation.
 Trauma → root fracture.
 Advanced pulp inflammation may involve supplemental structure cause its damage.
 Mobility may be associated with pain or pain is absent which indicates → chronic
Degeneration.
 Sensitivity to percussion
Start with gentle tapping by the tip of finger, then proceed
using back of mirror
Indicates:
 Acute pulpal inflammation in 2 direction
-axial ''periapical''
-lateral ''periodontal''
 In some conditions tooth mobility & sensitivity to percussion
or pressure may be a sign of high restoration, advanced
periodontal disease. However
 Vitality test:
 Although vitality test is not reliable tool in children as false results may be due
to :
 Child apprehension.
 Transmition of stimuli to gingival, periodontal ligament and bone but still
should be kept in consideration
 Pulp testing are:
1-Thermal pulp testing:
 Hot → hot gutta purcha, hot instrument
 Cold → ethyl chloride, ice sticks (H2O freezed in empty L.A carpule)
 Technique: apply first on normal tooth to allow child experience normal
response which is pain on application that disappears on removal of stimulus
 If pain persists longer → pulpities
 No pain → non-vital pulp.
 Limitations :
 No reliable evidence about degree of pulp disease (inflammation).
 Affected by size of pulp champer (difficult with small size pulp champer).
2-Electric pulp testing:
 Using electric pulp tester (electric vitalometer)
 First record reading of normal tooth, then record reading of affected one and
observe:
-Respond at higher level : pulp degeneration
-Respond at lower level: hyperemia or pulpities
-No response: necrosis (non vital)
 Limitation:
 Electric pulp irritation
 False +ve in case of:
- Liquefaction necrosis
- Pulpless tooth in contact with vital one by crown or ortho. Appliance
- Single vital canal
-Loss of child confidence if apprehensive
 Radiographic examination
 Periapical & bitewing x-rays
 Radio interpretation is more different in children > adults due to:
1- Young permanent teeth with incomplete root formation → periapical RL.
2- Physiologic root –ve → pathological condition
3- Superimposition of permanent on primary
 Radio evaluation covers:
1- Anatomical aspects:
-shape, size, length and number of roots (PA)
-Divergence of roots (PA)
-Location of pulp horns (BW)
2- Pathological aspects:
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proximity of caries to pulp (BW)
Internal –ve (PA, BW)
periapical (permanent) or furcation (primary) involvement (PA, BW)
Thickness of P.M space (PA)
reparative dentine (BW)
3- Developmental aspects:
 stage of development: root formation/ apical closure/ physiologic –ve stage of
succadaneous tooth eruption (PA)
 degree of pulp maturity: size of chamber (BW) / width of root canal (PA)
 Others: dens in dent (BW, PA) - absence of successor (PA) - taurodontism
(PA, BW)
Physical condition of child:
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Physical condition of child plays an important role in decision of pulp treatment.
Seriously ill child suffering from:
Heart disease
Nephritis
Leukemia
Solid tumors (malignant)
Cyclic neutropenia
-Should not be subjected to possibility of acute infection resulting from pulp therapy
-In addition, some systemic disease may affect the regenerative power of pulp following
pulp capping
-So in such cases proper premedication and extraction
Treatment of deep carious lesions
Vital pulp therapy for primary teeth:
 Indirect pulp capping:
-Definition: it is the process in which only gross caries is removed &
cavity is properly sealed (extremely important) for certain (6-8
week) time using bactericidal agent.
-Aim: preserve pulp vitality, arrest caries process (rationale).
-
 Advantage: (IPC).
1- Preserve vitality
2-Saves tooth strength & tooth integrity
3-Arrests activity of caries process by sealing off & destroying reaming microorganism
4-Promotes reparative dentin formation

Indications: (IPC).
1- Young primary & permanent teeth → having high reparative &
regenerative power.
2-Deep carious lesion approximating pulp not involving it
3-Absence of any sign of spontaneous pain
4-Vital pulp
5-Normal radiograph findings
6-Good physical condition of patient
7-Restorable
Contraindication:( IPC).
1-aged pulp in a mature primary teeth
Decrease regenerative potential of pulp
Resorption > 2/3 root
2-non-vital pulp
3-history of spontaneous pain
4-tooth decayed beyond repair or near exfoliation
5-existing pathologic pulp exposure
Contraindication (IPC) Follow.
6-radiographic evidences of pulp pathos is :
 Bifurcation involvement.
 Internal –ve.
 Widening of periodontal membrane space at periapical.
 Calcific mass in pulp.
7-mobility or fistulus tract.
Evaluation:
-After 6-8 weeks, evaluate treated tooth for success of treatment (criteria of
success of treatment)
1-restoration is intact
2-absence of adverse clinical sign & symptoms:
a- pain b-swelling c-mobility d- sensitivity to percussion e-tooth still vital
3-radiographic evidence of favorable responses
R.O as an evidence of sclerosis & remineralization
Decrease pulp size → reparative dentine formation
No abnormal root or radicular diseases.
Direct pulp capping
-Definition:
 It is the procedure of covering exposed vital pulp using capping material to
promote healing & preserve pulp integrity and vitality.
 -Advantages:
1-preserve vitality
2-Saves tooth structure & tooth integrity
3-Arrests activity of caries process by scaling off and destroying microorganisms
4-Promotes reparative dentine formation
 -Indications: (DPC).
1- Limited to traumatic exposure i.e. iatrogenic in isolated field
2-Small pin –point (< 1mm) non hemorrhagic, surrounded by sound dentine
3-Recent exposure; the patient reported immediately or within 2-6 hours
4-Vital pulp with no sign of painful pulpities
5-No or min bleeding
6-Normal radio findings
7-Normal physical condition of patient
8-Open or closed apices (open > close)
Contraindications: (DPC).
1- Aged pulp
The success of pulp capping depends on the presence of young active U.M.Cs which is
induced odontoblastes which form secondary dentine .
2-abnormal radiographic finding
-Internal or external
-Radiolucent finding
-Bifurcation involvement
-Calcfic mass in pulp
-Abnormal widning of periodontal
Follow contraind. Of (DPC).
3-Non vital pulp
4-Mobility or vistula tract
5-Tooth affected beyond repair
6-History of spontaneous pain
Pulpotomy
-Definition:
It is the complete amputation of coronal pulp tissues till the entrance of radicular pulp
followed by medicated placement over radicular pulp to stimulate repair and reserve
the remaining vital radicular pulp.
-Advantages:
1. Prserve tooth till normal shedding
2. Highest success rate (98%)
3. Easness of treatment
4. Economic
5. Single visit technique
 Indications of pulputomy :
1-Carious or traumatic exposure in vital primary teeth when
-Exposure size > 1 mm (pin point)
-Slight bleeding considered normal
2-Restorable tooth
3-No history of spontaneous or persistant pain
4-Normal radio. Findings
 No internal –ve
 No interradicular bone loss
 No widening of lamina dura
Follow indication of pulptomy:
5-No abscess ''vital'', no sinus ''no mobility''
6-Clinical signs of normal pulp canals i.e controlled bleeding with
direct pressure
7-Good physical condition
 Contraindications of pulpotomy :
1-Clinical signs of:
 Hg. not controlled by direct P following pulp (coronal) amputation
 Necrotic pulp or pus discharge
 Fistulus tract
 Mobility
 Swelling
 Pain on percussion
2-Radio. Signs of:
 Periapical or inter radicular R.L
 Internal –ve
 Advanced external –ve
3-Chronically ill child (cardiac patients) ''poor physical condition''
Technique:
A) Materials:
1- Diagnostic set
2-L.A
3-Rubber dam
4-High speed pear or fissure bur for cavity pressure
5-Low speed long shank round (rose -head) bur no4 or 5
6-Spoon excavator (sharp)
7-materials used in vital pulp cont.
 According to material used, pulpotomy is classified into:
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Formocresol pulpotomy
Ca(OH)2 pulpotomy
Gluteraldhyde pulpotomy
Ferric Sulphate pulpotomy
Devitalization pulpotomy (paraformaldehyde)
Laser pulpotomy
Electrosurgry pulpotomy
Other experimental material:
 BMP
 MTA
 Freezed dried bone
 Formocresol pulpotomy:
 One step technique
 Criteria for single visit :
1-No pain (proper analgesia)
2-No blood oozing
3-Cooperative child
4-Enough time.
 Cotton pellets moistened with 1/5 dilution formocresol
 Remove excess of formocresol by dapping on cotton roll
 Place over orifices of R.C for 3-5 mins → dark brown orifices with min oozing of
blood
 Zno/E pastes placed over pulp stumps and tapped gently
 Final restoration ''st.st & amalgum''
 2 steps technique:
-Why?
1- If no sufficient time to finish in first visit
2-Uncooperative child
-Technique:
 Same as single visit except:
 Place cotton pellet with formocresol in the floor of pulp chamber and temporary
filling
 Second visit after 2-3 days
 Remove cotton after isolation with rubber dam (L.A)
 Restore in usual manner
 Indications of formocresol pulpotomy
1-Vital primary tooth with carious or accidental exposure
2-clinical signs of normal pulp canal.
 Contraindications
1-spontaneous pain
2-swelling
3-fistula
4-percussion tenderness
5-pathological mobility
6-external or internal root resorption
7-pulp calcifications
8-periapical or interradicular radiolucency
9-profuse hemorrhage
10-exudates
 Evaluation: Pulpotomy.
1-Asymptomatic tooth
2-No mobility or fistulae
3-No furcation radioucency
4-No internal/external root resorption.
Devitalization pulpoyomy (2 steps pulpotomy)
The generally accepted pulp treatment for primary teeth is the
formocresol pulpotomy. However in some circumstances single visit
formocresol pulpotomy cann't be achived due to:
Insufficient time avalible
Pulpal inflammation makes it difficult to achieve profound analgesia
for pulp amutation
Limited patients cooperation.
First visit:
 The technique involves placement of paraformaldehyde paste over the exposed
pulp (after being sure that the exposure site free of debris) & sealed for 1-2
weeks using quick set Zno/E
Second visit:
 No local anesthesias, isolate, remove dressing & paraformaldehyde paste and
inspect if no sensitivity or bleeding from exposure site, procedure in usual
manner (3-6 formocresol pulpotomy)
Calcium Hydroxide pulpotomy
-Indications

1- Small exposure
2- The patient reported late within less than 12 hours
3- Large exposure & patien reported immediate
4- Vital tooth with no symptoms of painful pulpities
5- Incompletely formed roots (open apices)
-Non-vital pulp therapy for primary teeth
 Non-vital pulpotomy ''mortal pulotomy''
Ideally a non vital tooth should be treated by pulpectomy and root canal filling.
-Technique:
 First visit
-Necrotic coronal pulp is removed as pulpotomy & infected radicular pulp is treated with
strong antiseptic solution.
→ formocresol
→Comforated monochlorophenol (CMP)
-Material is applied on cotton pledget & sealed in pulp for 1-2 weeks.
-Strong antiseptic action of these solutions combats infection in radicular pulp.
Second visit
Antiseptic solution is removed & replaced by antiseptic paste (Eudenol, formocresol
& zinc oxide powder)
Press antiseptic paste firmly into root canal with a cotton pellet.
Pressure forces paste down root canal compressing pulp tissue apically.
Restore tooth as usual (chrome steel crown).
-presence of sinus with chronic abscess or of some degree of tooth mobility is not a
contraindication for this method.
-sinus →expected to disappear following control of infection
 Mobile tooth →becomes firm as periapical bone reforms
 A tooth with acute abscess may be treated by this method after
draining pus & controlling infection.
 -Failure may be occur → sinus & fistula remains → tooth mobility
→ extraction
 -success in very young children (3years) → no root resorption &
healthy child.
 -77% success rate after 3 years and follow up
Pulpectomy
Pulpectomy is apexified(closed) permanent teeth is conventional root
canal (endodontic) treatment for exposed, infected, and/or necrotic
teeth to eliminate pulpal and periradicular infection.
Indications of pulpectomy :
a- Dry pulp chamber when tooth is opened
b-Accessible root canals
c-Intra- radicular bony involvement without loss of bony support
d-Continued adverse sign and symptoms following
pulpotomy ''excessive hemorrhage that is not controlled
with damp cotton pellet applied for several minutes''
Follow indication of pulpectomy:
e-Strategic tooth e.g lower E with necrotic pulp before eruption of lower 6 or
lower E with no successor lower 5 so longer retention is required
f-Cooperative patient
g-In permanent teeth: indicated for a restorable permanent tooth with irreversible
pulpitis or a necrotic pulp in which the root is apexified (closed).
Contraindication of pulpectomy:
a- Excessive periapical involvement or mobility
b-Excessive root resorption
c-Excessive internal resorption (perforate bifurcation)
d-Chronically ill child ''congenital or rheumatic heart disease & children on long
term corticosteroid therapy or immunocompromised''
e-Tooth near exfoliation
f-Fear of spread of infection to successor
g-Uncontrolable child
-Technique: pulpectomy
1- Local anesthesia
2-rubber dam application (cotton roll & saliva ejector)
3-remove infected carious dentine before entering pulp chamber to avoid intrusion of
microorganisms into pulp canals
4-using sterile fissure bur enter pulp chamber through exposure site or at area of the
pulp horn, complete deroofing using round bur
5-amputate coronal pulp tissue with a sharp excavator to the end of the orifice of the
canal; avoid using bur to avoid perforation of bifurcation area
6-the root canals are debrided and shaped with hand or rotary files
7-instrumentation and irrigation with an inert solution alone cannot adequately reduce
the microbial population in a root canal system. So disinfection with irrigants such as
1% sodium hypochlorite and/or chlorhexidine is an important step in assuring
optimal bacterial decontamination of the canals.
N.B: sodium hypochlorite must not be extruded beyond the apex.
8-after the canals are dried, a resorbable material such as:
-non reinforced Zinc/oxide eugenol,
-iodoform- based paste (KRI),
Or a combination paste of iodoform and calcium hydroxide (Vitapex ,Endflax) is used
to fill the canals.
-Follow technique of pulpectomy:
9-root canal obliterating equipment:
 Lentulo spiral method (lentulo spiral)
 Master point method (additional glass slab, root canal plunger)
 Pressure syringe method (pressure syringe, barrel syringe, screw type
plunger, 2 wrench)
10-The tooth is restored with a restoration that seals the tooth from
microleakage.
Vital pulp therapy for young permanent teeth

Partial pulpotomy for carious exposure:
Procedure:
-inflamed pulp tissues are removed to a depth of 1-3 mm or deeper to reach
healthy pulp tissues.
- control pulp bleeding & irrigation with saline , Nahcl
- MTA or Ca(OH)2 capping
- Restoration
Indications:
 Vital tooth
 Open apex
 Exposure more than 2 mm
 No history of spontaneous pain
 1-2 min. enough to control bleeding
Objectives:
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Preservation of pulp vitality
Preservation of tooth integrity
Promote reparative dentine formation
Promote normal physiological root development apex closure.
Favorable sign &symptoms:
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No post operative pain
No post operative swelling
No radiographic evidence of internal resorption, external resortion or calcification
Root completion.
Apexogenesis :
Definition:
Apexogenesis is a histological term used to describe the continued
physiological development and formation of the root's apex.
 Removal of pulp tissues till level of C.E.J in pulp chamber, preserving
the radicular pulp, promoting normal apical closure
N.B: indirect pulp capping or direct pulp capping or partial pulpotomy
all are considered apexogenesis .
Apexogenesis :
Indication:
 Treatment of young permanent teeth with carious exposure.
 Exposed teeth with no symptoms of painful pulpitis.
 Pulp exposure resulting from crown fracture.
 Permanent teeth with immature root develop- -ment but with
healthy pulp tissue.
 Good physical condition of the patient.
Method ( apexiogrnsis).
 Ca(OH)2 placed directly on radicular pulp stump stimulates a
calcific response immediately adjacent to it, then cement base
then final restoration.
 This is seen later on as radiographic ''bridge'' over amputation
site.
 Degenerative & irreversible coronal pulp changes have not
progressed into radicular pulp →successful root closure, then
endo treated immediately '' if Ca(OH)2 left long; degenerative
calcification''
 A periodic radiograph should be taken to confirm that no
pathologic periapical changes are present, also periodic
clinical evaluation is mandatory
Complications:
Although high success rate of Ca(OH)2 pulp has been reported (95%)
1- Internal resorbtion
2- Canal calcification
3- Pulp necrosis & abscess
Apexification (root end closure in non vital tooth)
Definition:
Apexification
is a method of treatment for immature permanent teeth in which root growth
and development ceased due to pulp necrosis, by removing the coronal and
non vital radicular tissue just short of the root end and placing a
biocompatible agent such as calcium hydroxide in the canals. The purpose
is to allow the formation of an apical barrier.
Indications of apexification:
 If a young permanent tooth has a pulp with extensive
degeneration or necrosis:
A-pulp should be totally debribed.
B-canal is treated with Ca(OH)2 ''direct contact with vital
tissue''
 Apexification is used to promote root elongation &/or a
calcific root closure.
Procedure:
 In apexification, entire pulp contents are removed to level of
radiographic apex using endodontic (broaches & files).
 Ca(OH)2 is placed at apical end of radicular canal → gradually
washes out → must be replaced every several months (3 month) till
apical closure occurs.
 A conventional endodontic procedure is done after apexification is
complete.
Radiographic evidence shouldn't be seen:
1-External root resortion
2-lateral root pathosis
3-Root fracture
4-Breakdown of periradicular supporting tissues during or following therapy
Outcomes of apexification after 6 month
1- Normal closure of canal & apex with normal radiographic application
2- Dome shape apical closure with canal retained BB application
 No apparent radio change but closure can be felt as +ve stop clinically using
plugger
Key factor of success of apexification
1- Proper infection control
2- Proper debridement
3- Proper cronal seal
4-Proper apical seal
Material used should have osteo-inductive property
1- Ca(OH)2
2- CMCP
3- Vitapex
4- Pulpdent
5- BMP
6-MTA
Drawbacks of apexicification
1- Long course of treatment .
2- Need patient cooperation.
3- Decrease fracture resistance.
4- Coronal leakage → decrease success rate .
Failures following vital pulp therapy
 Causes of failure:
Pre- operative causes:
-Misdiagnosis
-Improper case selection ''poor prognosis''
Operative causes:
-Iatrogenic errors
-Perforations
-Ledges
-Longitudinal fracture
Post-operative causes:
-Improper selection of restorable material
-Trauma
-Fracture
Criteria of failure:
Radiographic:
Increase periapical or bifurcation radiolucent
Increase intraligmental space
Loss of lamina dura
Root resorption
Clinical
Persistant symptoms
Sinus
Pain on percussion
Mobility.
Thank you for your
attention…..