Pulp Therapy in Pediatric Dentistry: Complete and Updated Guide

Pulp therapy in pediatric dentistry includes a wide range of procedures aimed at preserving pulp health and tooth function in both primary and immature permanent teeth.

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Treatment choice depends on pulp vitality status, lesion extent, and clinical and radiographic features. This article reviews the available procedures, biomaterials, commercial brands, diagnostic criteria, and post-treatment rehabilitation options.

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Introduction
The dental pulp plays a critical role in tooth vitality, defense, and root development. In pediatric dentistry, pulp therapy aims to maintain primary teeth until physiological exfoliation and to allow root maturation in young permanent teeth. Success depends on accurate diagnosis, proper case selection, and the use of biocompatible and evidence-based materials.

A. Vital Pulp Therapies

1. Indirect Pulp Capping
° Definition: Placement of a biocompatible material over affected but not infected dentin.
° Indications: Deep caries without pulp exposure.
° Materials & Brands:
➤ Calcium hydroxide (Dycal®).
➤ Glass ionomer cements (Vitrebond™, Fuji IX®).
➤ Mineral trioxide aggregate (MTA) (ProRoot® MTA).

2. Direct Pulp Capping
° Definition: Placement of material directly over a small pulp exposure under controlled conditions.
° Materials & Brands:
➤ MTA (ProRoot®, Angelus®).
➤ Biodentine™.
➤ Calcium hydroxide.

3. Pulpotomy
° Definition: Removal of coronal pulp while preserving healthy radicular pulp.
° Techniques:
➤ Formocresol (Buckley’s solution, now obsolete due to toxicity).
➤ Calcium hydroxide pulpotomy.
➤ MTA or Biodentine™ pulpotomy (current gold standard).

4. Apexogenesis (in immature permanent teeth)
➤ Definition: Maintains pulp vitality to allow continued root development and apical closure.
➤ Materials: MTA, Biodentine™, calcium hydroxide.

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B. Non-Vital Pulp Therapies

1. Pulpectomy
° Definition: Complete removal of necrotic pulp and root canal filling.
° Indications: Necrosis, abscess, chronic pulpitis.
° Filling Materials & Brands:
➤ Zinc oxide-eugenol (ZOE).
➤ Iodoform-based pastes (Vitapex®, Metapex®).
➤ Calcium hydroxide-based pastes (Sealapex®).

2. Apexification (in immature permanent teeth)
° Definition: Induction of apical closure in necrotic immature permanent teeth.
° Materials: MTA (ProRoot®, Angelus®), calcium hydroxide.

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C. Clinical and Radiographic Diagnosis

➤ Vital teeth:
° Clinical: Mild provoked pain, no spontaneous pain, no pathologic mobility, normal thermal sensitivity.
° Radiographic: Normal pulp chamber, no periapical lesion, possible slight widening of periodontal ligament.

➤ Non-vital teeth:
° Clinical: Spontaneous or lingering pain, sinus tract, swelling, discoloration, pathologic mobility.
° Radiographic: Periapical radiolucency, pathological root resorption, widened periodontal ligament.

📊 Comparative Table: Signs and Symptoms in Vital Teeth

Aspect	Signs & Symptoms
Pain	Mild, provoked, disappears when stimulus is removed
Mobility	Absent or within physiologic limits
Tooth color	Normal
Radiograph	No periapical radiolucency; periodontal ligament normal

📊 Comparative Table: Signs and Symptoms in Non-Vital Teeth

Aspect	Signs & Symptoms
Pain	Spontaneous, persistent, or absent in advanced necrosis
Mobility	Pathologic, associated with periapical inflammation
Tooth color	Darkened or discolored
Radiograph	Periapical radiolucency, pathological root resorption, widened PDL space

D. Post-Pulp Therapy Restorative Treatments

° Temporary restorations: Glass ionomer cement.
° Definitive restorations: Composite resins, stainless-steel crowns, zirconia crowns for esthetics in primary teeth.
° Permanent teeth: Adhesive restorations, inlays/onlays when required.

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💬 Discussion
The success of pulp therapy relies on proper diagnosis, selection of a biocompatible material, and adequate restoration. While formocresol was once considered the standard, modern materials such as MTA and Biodentine™ have demonstrated higher biocompatibility and superior outcomes. Current pediatric endodontics favors vital pulp therapies whenever possible and effective disinfection and resorbable fillings for necrotic cases.

✍️ Conclusion
Pulp therapy in pediatric dentistry is fundamental for preserving primary teeth until natural exfoliation and supporting root maturation in young permanent teeth. Correct diagnosis, appropriate therapy selection, and immediate restorative treatment are key to long-term success. Modern biomaterials like MTA and Biodentine™ offer greater predictability and safety than traditional options.

📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2022). Guideline on pulp therapy for primary and immature permanent teeth. Pediatric Dentistry, 44(6), 343–351.

✔ Fuks, A. B., & Peretz, B. (2021). Pediatric Endodontics: Current Concepts in Pulp Therapy for Primary and Young Permanent Teeth. Springer.

✔ Parirokh, M., & Torabinejad, M. (2010). Mineral trioxide aggregate: a comprehensive literature review—Part III: Clinical applications, drawbacks, and mechanism of action. Journal of Endodontics, 36(3), 400–413. https://doi.org/10.1016/j.joen.2009.09.009

✔ Coll, J. A., Vargas, K., Marghalani, A. A., Chen, C. Y., & Dhar, V. (2017). A systematic review and meta-analysis of nonvital pulp therapy for primary teeth. Pediatric Dentistry, 39(1), 16–123.

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Terapia Pulpar en Odontopediatría: Guía Completa y Actualizada

La terapia pulpar en odontopediatría constituye un conjunto de procedimientos destinados a preservar la salud y función del tejido pulpar en dientes temporales y permanentes inmaduros.

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Su elección depende del estado vital o necrótico de la pulpa, la extensión de la lesión y las características clínicas y radiográficas. Este artículo revisa los tratamientos disponibles, los materiales empleados, su diagnóstico y las alternativas rehabilitadoras posteriores.

Enlaces Patrocinados

Introducción
La pulpa dental desempeña un papel esencial en la vitalidad, defensa y desarrollo radicular del diente. En odontopediatría, el objetivo principal de la terapia pulpar es mantener los dientes temporales hasta su exfoliación fisiológica y favorecer la maduración radicular en dientes permanentes jóvenes. El tratamiento adecuado depende de un diagnóstico preciso y del uso de materiales biocompatibles, predecibles y clínicamente comprobados.

A. Terapias pulpares en dientes vitales
Incluyen procedimientos destinados a preservar parcial o totalmente la pulpa dental:

1. Protección pulpar indirecta
° Definición: Se coloca un material biocompatible sobre dentina afectada pero no infectada.
° Indicaciones: Caries profundas sin exposición pulpar.
° Materiales: Hidróxido de calcio (Dycal®), ionómero de vidrio (Vitrebond™, Fuji IX®), MTA (ProRoot® MTA).

2. Protección pulpar directa
° Definición: Colocación de material sobre exposición pulpar pequeña en condiciones controladas.
° Materiales: MTA (ProRoot®, Angelus®), Biodentine™, hidróxido de calcio.

3. Pulpotomía
° Definición: Remoción de pulpa cameral preservando la radicular.
° Tipos:
➤ Convencional (formocresol) – Buckley’s Formocresol (actualmente en desuso por toxicidad).
➤ Con hidróxido de calcio.
➤ Con MTA o Biodentine™ (técnicas de elección por mayor biocompatibilidad).
° Indicaciones: Exposición pulpar en dientes vitales sin signos de necrosis.

4. Apexogénesis (en permanentes inmaduros)
° Definición: Mantiene la vitalidad de la pulpa radicular permitiendo cierre apical fisiológico.
° Materiales: MTA, Biodentine™, hidróxido de calcio.

B. Terapias pulpares en dientes no vitales

1. Pulpectomía
° Definición: Extirpación total de la pulpa radicular necrótica y obturación de conductos.
° Indicaciones: Necrosis pulpar, abscesos, inflamación crónica.
° Materiales de obturación:
➤ Pasta de óxido de zinc-eugenol (ZOE).
➤ Pasta iodoformada (Vitapex®, Metapex®).
➤ Pasta a base de hidróxido de calcio (Sealapex®).

2. Apexificación (en permanentes inmaduros)
° Definición: Inducción del cierre apical en dientes con necrosis.
° Materiales: MTA (ProRoot®, Angelus®), hidróxido de calcio.

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C. Diagnóstico clínico y radiográfico

1. En dientes vitales:
° Clínico:
➤ Dolor provocado leve, ausente al retirar estímulo.
➤ No dolor espontáneo.
➤ Sin movilidad patológica.
➤ Sensibilidad térmica normal.
° Radiográfico:
➤ Cámara pulpar normal.
➤ Sin rarefacción periapical.
➤ Ensanchamiento leve de ligamento periodontal en algunos casos.

2. En dientes no vitales
° Clínico:
➤ Dolor espontáneo o ausente (necrosis).
➤ Fístula, absceso, movilidad.
➤ Cambio de color dental.
° Radiográfico:
➤ Rarefacción periapical.
➤ Reabsorción radicular patológica.
➤ Espacio del ligamento periodontal irregular.

📊 Tabla comparativa: Signos y síntomas en dientes vitales

Aspecto	Signos y Síntomas
Dolor	Provocado, leve y desaparece al retirar el estímulo
Movilidad	Ausente o fisiológica
Color dental	Normal
Radiografía	Sin rarefacción periapical; ligamento periodontal normal

📊 Tabla comparativa: Signos y síntomas en dientes no vitales

Aspecto	Signos y Síntomas
Dolor	Espontáneo, persistente o ausente en necrosis avanzada
Movilidad	Patológica, asociada a inflamación periapical
Color dental	Oscurecido o con cambios cromáticos
Radiografía	Rarefacción periapical, reabsorción radicular o ensanchamiento periodontal

D. Tratamientos rehabilitadores posteriores
Tras la terapia pulpar, los dientes requieren restauración que asegure sellado y función:

° Restauraciones temporales: Cemento de ionómero de vidrio.
° Restauraciones definitivas: Resinas compuestas, coronas de acero inoxidable, coronas estéticas de zirconia en temporales.
°Permanentes inmaduros: Obturaciones adhesivas, incrustaciones según necesidad.

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💬 Discusión
El éxito de la terapia pulpar depende del diagnóstico correcto, la selección de material biocompatible y la rehabilitación adecuada. El formocresol, aunque históricamente usado, ha sido reemplazado por materiales como el MTA y Biodentine™ por su seguridad y éxito clínico. Los protocolos actuales buscan preservar la vitalidad pulpar siempre que sea posible y, en casos de necrosis, garantizar una desinfección efectiva con obturación resorbible en temporales.

✍️ Conclusión
La terapia pulpar en odontopediatría es un pilar en la conservación de dientes temporales y permanentes inmaduros. El diagnóstico clínico-radiográfico preciso, la elección correcta del procedimiento y la rehabilitación inmediata son claves para el éxito a largo plazo. El uso de materiales modernos como MTA y Biodentine™ ofrece mayor biocompatibilidad y mejores resultados que técnicas tradicionales.

📚 Referencias

✔ American Academy of Pediatric Dentistry (AAPD). (2022). Guideline on pulp therapy for primary and immature permanent teeth. Pediatr Dent, 44(6), 343–351.

✔ Fuks, A. B., & Peretz, B. (2021). Pediatric Endodontics: Current Concepts in Pulp Therapy for Primary and Young Permanent Teeth. Springer.

✔ Parirokh, M., & Torabinejad, M. (2010). Mineral trioxide aggregate: a comprehensive literature review—Part III: Clinical applications, drawbacks, and mechanism of action. Journal of Endodontics, 36(3), 400–413. https://doi.org/10.1016/j.joen.2009.09.009

✔ Coll, J. A., Vargas, K., Marghalani, A. A., Chen, C. Y., & Dhar, V. (2017). A systematic review and meta-analysis of nonvital pulp therapy for primary teeth. Pediatric Dentistry, 39(1), 16–123.

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Webinar: Pulp treatment for primary & immature permanent teeth - Dr Nadine Moelich

Pulp treatment for primary and immature permanent teeth is a cornerstone of pediatric dentistry, demanding accurate diagnosis and evidence-based decision-making.

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This webinar explores the latest approaches to preserving pulp vitality and ensuring proper root development in young patients.

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Treatment options range from traditional pulpotomy in primary teeth to advanced techniques for immature permanent teeth, where the choice of materials and clinical protocols directly influences long-term outcomes.

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Special emphasis is placed on apexogenesis, which encourages continued root development and apical closure, and apexification, a strategy for non-vital teeth that promotes apical barrier formation.

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📌 Watch webinar: "Pulp treatment for primary & immature permanent teeth - Dr Nadine Moelich"

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Pink Tooth in Dentistry: Etiology, Diagnosis, Treatment, and Forensic Relevance

The “pink tooth” phenomenon describes a pink discoloration of dentin visible through the enamel. It can occur both in living patients and postmortem.

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In clinical dentistry, it is associated with trauma, internal resorption, pulp necrosis, or iatrogenic staining, while in forensic contexts it has been linked to deaths caused by drowning, asphyxiation, or cranial trauma. This article reviews the causes, differential diagnosis, clinical and forensic implications, as well as available treatment options.

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✅ Introduction
Dental discolorations are a frequent reason for consultation. Among them, a pink hue in a tooth crown is of particular interest due to its varied etiology. For years, the pink tooth was thought to be exclusive to drowning or asphyxia victims. However, the literature shows that it may also occur in clinical ante mortem cases, associated with pathological or iatrogenic factors. This article aims to provide an updated and precise overview of this phenomenon.

✅ Etiology

➤ Ante mortem / Clinical

° Internal resorption: the most classic cause in living patients; inflamed and vascularized tissue behind the enamel gives rise to a pink shade.
° Dental trauma: intrapulpal hemorrhages diffuse blood pigments into dentin, creating a transient pink discoloration.
° Early pulp necrosis: tissue breakdown releases byproducts that stain dentin.
° Endodontic materials: some sealers and cements may cause pink or reddish staining in the crown.

➤ Post mortem / Forensic

° Caused by hemolysis and hemoglobin diffusion into dentinal tubules.
° Commonly observed in drowning, asphyxia, and cranial trauma, although not exclusive to these causes.
° Environmental factors such as temperature, humidity, and postmortem interval influence the intensity of discoloration.

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✅ Differential Diagnosis

° Medical and dental history: trauma, pulp vitality, prior treatments.
° Vitality tests (cold, heat, electric pulp test).
° Periapical radiography or CBCT to assess resorption extent.
° Differentiate from discolorations caused by systemic conditions, medications, or restorative materials.

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✅ Treatment and Clinical Management

° Initial internal resorption: root canal treatment with disinfection and obturation.
° Intracanal medications: calcium hydroxide between appointments.
° Prosthetic restorations or crowns in cases of structural loss.
° Extraction: last resort when the tooth is unrestorable or has extensive perforations.

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✅ Forensic Relevance

° The pink tooth may suggest drowning or asphyxia but is neither exclusive nor pathognomonic.
° Its probative value is limited and must be interpreted alongside other evidence.
° Intensity and localization of discoloration vary depending on anatomical and environmental factors.

📊 Comparative Table: Pink Tooth — Clinical vs. Forensic Causes

Aspect	Clinical Causes	Forensic Causes
Etiology	Internal resorption, pulp necrosis, dental trauma, endodontic sealers with pigments.	Drowning, mechanical asphyxia, severe cranial trauma, postmortem hematic diffusion.
Characteristics	Pink coloration visible in the pulp chamber or crown; may progress to reddish hues.	Intense pink coloration in the crown, usually homogeneous and associated with postmortem findings.
Relevance	Important for differential diagnosis in clinical dentistry to avoid confusion with forensic cases.	Auxiliary indicator in forensic investigations of criminal or accidental death.
Limitations	May be confused with staining caused by endodontic materials or chronic pulp lesions.	Not exclusive to asphyxia; must be correlated with other forensic findings.

💬 Discussion
The belief that the pink tooth is exclusive to drowning or asphyxia victims has been disproven. In living patients, it may result from internal resorption, trauma, pulp necrosis, or endodontic materials. Postmortem, it is more frequent in asphyxia or drowning, but may also occur under other conditions. Clinically, early diagnosis is essential for tooth preservation, while in forensic dentistry it should be interpreted as a nonspecific finding requiring correlation with other data.

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✍️ Conclusions
° The “pink tooth” is not exclusive to drowning or asphyxia.
° It may occur in both living patients (trauma, necrosis, resorption, materials) and postmortem (hemolysis).
° Early diagnosis improves clinical prognosis and prevents tooth loss.
° In forensic dentistry, it has indicative but not conclusive value for determining cause of death.

📚 References

✔ Carney, K. A., Colloc, T. N. E., & Kilgariff, J. K. (2024). Management of rarely seen internal tunnelling root resorption associated with a maxillary permanent incisor. British Dental Journal, 236(7504), 955–961. https://doi.org/10.1038/s41415-024-7504-7

✔ Nilsson, E., et al. (2013). Management of Internal Root Resorption on Permanent Teeth. Journal of Endodontics, 39(12), 1521–1527. https://doi.org/10.1016/j.joen.2013.08.020

✔ Minegishi, S., et al. (2022). Association of Cadaveric Factors with the Degree and Region of Discoloration in the Phenomenon of Pink Teeth. Applied Sciences, 12(9), 4242. https://doi.org/10.3390/app12094242

✔ Sumi, N., et al. (2023). Study on the Mechanism of the Pink Tooth Phenomenon. Diagnostics, 13(16), 2699. https://doi.org/10.3390/diagnostics13162699

✔ Regalado-Barrera, J. D., Hernández-Salas, C., Murillo-López, E., Reyes-Moreno, D. C., Cano-Sánchez, D., & Rosales-González, H. (2023). Etiology of the pink tooth: a curious postmortem phenomenon. Contexto Odontológico, 13(25), 23-28. https://revistas.uaz.edu.mx/index.php/contextoodontologico/article/view/2568

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Webinar: Tratamiento de necrosis pulpar en dentición primaria - Dra. Hayssel Chávez Vigil

El tratamiento de la necrosis pulpar en dentición primaria representa un desafío clínico que requiere un diagnóstico preciso, apoyado en la evaluación clínica y radiográfica para diferenciar lesiones reversibles de procesos irreversibles.

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En los casos con compromiso sistémico o infecciones agudas, el uso de antibióticos adecuados resulta esencial como terapia coadyuvante, siempre basándose en protocolos actualizados y en el control de la infección.

Enlaces Patrocinados

Entre las técnicas restauradoras más empleadas destacan la técnica de CTZ, que combina propiedades antimicrobianas y facilidad de aplicación en pacientes pediátricos, y la endodoncia no instrumentada, que se orienta hacia un manejo conservador y mínimamente invasivo, reduciendo el tiempo clínico y la ansiedad infantil.

Estas alternativas, unidas a una correcta selección de casos y seguimiento clínico, permiten conservar dientes primarios afectados, mantener la función masticatoria y guiar la erupción de la dentición permanente.

📌 VEA EL WEBINAR: "Tratamiento de necrosis pulpar en dentición primaria - Dra. Hayssel Chávez Vigil"

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