Pulp Therapy in Primary Teeth: A Clinical Review

Pulp therapy in primary dentition remains one of the most clinically challenging and frequently examined topics in pediatric dentistry. This article reviews the main treatment options with current evidence-based guidelines.

Why Pulp Therapy Matters in Primary Teeth

The primary goal of pulp therapy in primary teeth is to:

• Maintain the tooth in a functional, asymptomatic state
• Prevent premature loss and maintain space for the permanent successor
• Avoid spreading infection to adjacent teeth or permanent successors

Classification of Pulp Conditions

1. Normal Pulp

No symptoms, positive response to sensibility testing, radiographic bone intact.

2. Reversible Pulpitis

• Mild pain that resolves quickly after stimulus removal
• No spontaneous pain
• Treatment: Indirect Pulp Treatment (IPT)

3. Irreversible Pulpitis

• Prolonged pain after stimulus
• Possible spontaneous pain
• Treatment: Pulpotomy or pulpectomy depending on condition

4. Pulp Necrosis

• No response to sensibility testing
• Possible sinus tract or abscess
• Treatment: Pulpectomy or extraction

Treatment Options

Indirect Pulp Treatment (IPT)

Indication: Deep caries approaching pulp with no signs of irreversible pulpitis

Technique:

1. Remove infected dentin, leaving a thin layer of affected dentin over pulp
2. Apply biocompatible liner (MTA, calcium hydroxide, or glass ionomer)
3. Restore with final restoration

Success rate: 85–95%

Pulpotomy

Indication: Carious exposure in a primary tooth with vital coronal pulp, no signs of radicular pulp involvement

Medicaments (in order of evidence):

• MTA (Mineral Trioxide Aggregate) — gold standard, biocompatible, high success rate
• Formocresol — historically used, declining due to biocompatibility concerns
• Ferric Sulfate — hemostatic, good clinical outcomes
• Biodentine — newer alternative with excellent outcomes

Radiographic Success Criteria:

• No internal/external root resorption
• No furcation involvement
• Normal PDL space

Pulpectomy

Indication: Irreversible pulpitis or necrotic primary tooth that is restorable and strategic

Obturating Materials:

• ZOE paste — most commonly used, resorbable
• Calcium hydroxide + iodoform paste (Vitapex) — preferred for necrotic teeth

Key Principle: The material MUST be resorbable at the same rate as primary tooth roots.

Common Exam Questions on This Topic

• What is the ideal medicament for pulpotomy in primary molars? → MTA
• Which obturating material is used in pulpectomy of primary teeth? → ZOE or Vitapex
• What is the main contraindication for pulp therapy in primary teeth? → Less than 2/3 root remaining, pathological root resorption, non-restorable tooth

Conclusion

Understanding pulp therapy in primary teeth is essential for the Prometric exam. Focus on indications, contraindications, and the rationale behind material selection — these are consistently tested areas.