Vital Pulp Therapy in Primary Teeth: Evidence-Based Approaches

Vital pulp therapy (VPT) in primary teeth aims to preserve the vitality and function of the dental pulp after carious or traumatic exposure. Its ultimate goal is to maintain primary teeth until their natural exfoliation, ensuring arch integrity, mastication, and normal development of permanent successors.

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Over the last decades, research has led to an evolution of techniques and materials, moving toward biocompatible, evidence-based approaches.

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✅ Definition of Vital Pulp Therapy Techniques

1. Indirect Pulp Treatment (IPT)
Indirect pulp treatment involves leaving a thin layer of affected but not infected dentin to avoid pulp exposure. A biocompatible liner is placed to encourage dentin remineralization and pulp healing.
➤ Current materials: calcium hydroxide, resin-modified glass ionomer, mineral trioxide aggregate (MTA), and calcium silicate-based cements.

2. Direct Pulp Capping (DPC)
Direct pulp capping is performed when a small mechanical or traumatic pulp exposure occurs. A bioactive material is applied directly over the pulp to stimulate reparative dentin formation.
➤ Current materials: MTA, calcium hydroxide, and newer bioceramics (Biodentine®).

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3. Pulpotomy
Pulpotomy is the most widely used VPT technique in primary teeth. It involves removal of the coronal pulp tissue, preserving radicular pulp vitality.
➤ Current medicaments: formocresol (historically used but controversial), ferric sulfate, MTA, Biodentine®, and sodium hypochlorite as hemostatic agents.

4. Pulpectomy (Non-Vital Alternative)
Although technically not a vital pulp therapy, pulpectomy is often considered in the treatment plan when pulp vitality cannot be preserved. It involves complete removal of pulp tissue and obturation of root canals with resorbable materials.
➤ Current medicaments: iodoform-based pastes (Vitapex®), calcium hydroxide-iodoform combinations.

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💬 Discussion
Current evidence strongly favors biocompatible and bioactive materials such as MTA and calcium silicate-based cements over traditional agents like formocresol, due to their improved outcomes in terms of pulp healing, dentin bridge formation, and biocompatibility (Farsi et al., 2023). The choice of technique depends on pulp status, extent of caries, and presence of symptoms. While IPT and DPC are conservative, pulpotomy remains the gold standard for cariously exposed but vital pulp.
Long-term clinical trials indicate that MTA and Biodentine® outperform traditional materials in terms of success rates and reduced adverse effects (Gomes et al., 2022). Nonetheless, cost and handling characteristics remain barriers in some clinical settings.

✍️ Conclusion
Vital pulp therapy in primary teeth is essential to maintain function and arch stability until natural exfoliation. Evidence-based protocols support the use of bioactive cements such as MTA and Biodentine®, which demonstrate superior clinical and histological outcomes compared to traditional agents. The clinician’s decision should integrate pulp vitality assessment, child cooperation, and material availability.

📊 Vital Pulp Therapy Techniques in Primary Teeth

Technique	Advantages	Limitations
Indirect Pulp Treatment (IPT)	Preserves pulp vitality; high success rate; conservative	Risk of residual caries; requires good sealing
Direct Pulp Capping (DPC)	Promotes reparative dentin formation; maintains pulp vitality	Lower success in carious exposures; best for mechanical exposures
Pulpotomy	Effective in symptomatic exposures; long-standing clinical success	Technique sensitive; controversy over medicaments
Pulpectomy	Option for non-vital teeth; preserves tooth until exfoliation	Not a true VPT; complex procedure; risk of failure in resorption

📚 References

✔ Farsi, N., Bawazir, O., & Al-Shahrani, A. (2023). Clinical and radiographic success of pulpotomy in primary teeth using mineral trioxide aggregate and Biodentine: A systematic review and meta-analysis. International Journal of Paediatric Dentistry, 33(1), 35–45. https://doi.org/10.1111/ipd.13013
✔ Gomes, A. C., Lima, T. F., Soares, D. G., & Hebling, J. (2022). Vital pulp therapy in primary teeth with calcium silicate-based materials: A systematic review. Journal of Dentistry, 120, 104102. https://doi.org/10.1016/j.jdent.2022.104102
✔ American Academy of Pediatric Dentistry (AAPD). (2022). Guideline on pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry, 403–412. https://www.aapd.org/research/oral-health-policies--recommendations

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Pediatric Dental Crowns: Indications, Benefits, and Long-Term Success

Pediatric dental crowns are widely used in the restoration of primary teeth with extensive decay, developmental defects, or after pulp therapy.

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This article reviews current evidence regarding their indications, benefits, and long-term success, focusing on stainless steel crowns (SSCs), zirconia crowns, and recent advances.

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✅ Introduction
Restoring severely decayed primary teeth poses a significant challenge in pediatric dentistry. Conventional fillings often fail due to limited durability and the complexity of managing caries in children. Pediatric dental crowns, particularly stainless steel and zirconia crowns, provide a reliable restorative option. Their role in maintaining arch integrity, mastication, and aesthetics has made them a cornerstone in modern pediatric restorative dentistry.

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✅ Indications

° Extensive caries affecting multiple tooth surfaces.
° After pulpotomy or pulpectomy procedures.
° Developmental anomalies such as amelogenesis imperfecta or dentinogenesis imperfecta.
° Fractured teeth requiring coverage.
° Cases where behavior management limits frequent re-interventions.

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✅ Types of Pediatric Crowns

° Stainless Steel Crowns (SSC): Gold standard for posterior teeth due to durability and cost-effectiveness.
° Zirconia Crowns: Increasingly used for anterior and posterior restorations, offering superior aesthetics.
° Resin-veneered Crowns: Intermediate option balancing aesthetics and functionality.

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✅ Benefits

° Provide full coverage protection against recurrent caries.
° High survival rates in comparison to amalgam or composite restorations.
° Improve chewing function and preserve arch length.
° Aesthetic options (zirconia) enhance parental and patient satisfaction.

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✅ Long-Term Success

° Survival rates: SSCs demonstrate over 90% success rates at 5 years (Innes et al., 2015).
° Zirconia crowns: Show comparable survival with better aesthetics but require precise tooth preparation.
° Parental satisfaction: Significantly higher for zirconia crowns due to aesthetics (Walia et al., 2014).

📊 Tabla comparativa: Pediatric Dental Crowns

Aspecto	Ventajas	Limitaciones
Stainless Steel Crowns (SSC)	High durability, cost-effective, >90% survival	Poor aesthetics, metallic appearance
Zirconia Crowns	Superior aesthetics, high parental satisfaction, biocompatible	Require extensive tooth preparation, higher cost
Resin-Veneered Crowns	Balance between cost and aesthetics	Prone to veneer fracture and wear
Long-Term Outcomes	High survival rates, preservation of arch integrity	Technique-sensitive, dependent on case selection

💬 Discussion
The literature strongly supports the use of pediatric crowns as a superior restorative option for severely compromised primary teeth. While stainless steel crowns remain the most cost-effective and durable, zirconia crowns address increasing parental demands for aesthetics. However, zirconia requires more aggressive tooth reduction, which may limit its indications in certain cases.
The long-term success of pediatric crowns is linked to proper case selection, clinical technique, and patient cooperation. Advances in adhesive dentistry and biomimetic materials may further enhance restorative outcomes, but crowns continue to hold a key role in comprehensive pediatric oral care.

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✍️ Conclusion
Pediatric dental crowns are the treatment of choice for extensively damaged primary teeth, providing excellent durability, functional preservation, and, with modern options, improved aesthetics. Both stainless steel and zirconia crowns demonstrate high long-term survival rates. Future research should focus on minimally invasive approaches that combine aesthetics with biological preservation.

📝 Reference

✔ Innes, N. P., Ricketts, D., & Evans, D. J. (2015). Preformed metal crowns for decayed primary molar teeth. Cochrane Database of Systematic Reviews, 2015(12), CD005512. https://doi.org/10.1002/14651858.CD005512.pub3
✔ Walia, T., Salami, A. A., Bashiri, R., Hamoodi, O. M., & Rashid, F. (2014). A randomized controlled trial of three aesthetic full-coronal restorations in primary maxillary teeth. European Journal of Paediatric Dentistry, 15(2), 113–118.
✔ Choi, S. C., Park, J. H., Kim, J. H., & Shin, Y. (2018). Clinical outcomes of preformed zirconia crowns in primary molars: A 24-month prospective study. Journal of Dentistry for Children, 85(3), 107–112.

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