Pulp Therapy for Primary and Immature Permanent Teeth: Indications and Objectives

Board takeaway

• Establish the diagnosis: pulp status, restorability, dentition, root development, and infection status.
• Preserve treatable vital pulp: an immature permanent tooth benefits from continued root development and thicker dentinal walls.
• Change pathways for necrosis or established infection. Spontaneous pain is not synonymous with necrosis.
• Selected spontaneous-pain cases: the 2026 best practice permits calcium-silicate pulpotomies when infection is absent and suitable vital radicular tissue remains.
• Defend the whole plan: case selection, coronal seal, alternatives, and follow-up—not a procedure chosen from pain alone.

Choose the right pulp reference

Diagnose before treating

• Integrate medical/dental history, pain location, intensity, duration, triggers, relief and spontaneity; examine soft/hard tissues, palpation, percussion and mobility; obtain diagnostic radiographs when possible.
• Brief provoked pain resolving with stimulus removal or other described relief, without irreversible-pulpitis findings, supports reversible pulpitis.
• Sinus tract, unexplained swelling/mobility, furcation/apical radiolucency or pathologic resorption raises concern for irreversible disease/necrosis. Spontaneous pain alone does not automatically exclude all vital therapy.
• Thermal/electric tests are less reliable in primary/immature teeth; sensibility cannot establish inflammation severity or healing capacity.
• Deep caries: two-thirds to three-quarters of dentin thickness, with a remaining dentin barrier. Extremely deep: full dentin thickness, without a discernible radiographic barrier.
• Slow lesions may stimulate reactionary dentin; severely inflamed exposed pulp may still form reparative dentin after suitable intervention.
• Consider extraction when infection cannot be controlled, bone support cannot recover, restoration is infeasible, or pathologic resorption is excessive. Document diagnosis, alternatives, prognosis, treatment and follow-up.

Caries control and procedural safety

• Selective removal preserves deepest affected dentin to avoid exposure; stepwise removal uses staged excavation; complete removal creates more exposures. Consider cooperation, anesthesia, medical history and family preferences.
• Prior silver diamine fluoride treatment may reduce additional excavation/vital-therapy needs.
• Rubber dam is the isolation standard; use other effective isolation when it cannot be applied.
• Dispense pulp irrigants through a single-use syringe: sterile water/saline or sodium hypochlorite as appropriate. Avoid tap water and dental-unit waterlines, including units supplied by independent reservoirs.
• Prevent sodium hypochlorite extrusion beyond the apex.

Primary teeth: vital options

Protective liner

• Optional thin biocompatible barrier in a deep preparation after complete caries removal with normal pulp.
• Goals: vitality, healing/tertiary dentin and reduced sensitivity/leakage.

Indirect pulp treatment (IPT)

• Deep caries, normal/reversibly inflamed vital pulp, no radicular pathology.
• Selectively leave deepest dentin, cover and seal.
• Liner choice does not affect IPT success; routine reentry lacks conclusive support.
• Long-term studies favor IPT over direct cap/pulpotomy.
• Glass-ionomer interim restorations can control caries while pulp status is assessed.

Direct pulp cap

• Normal pulp with a small < 1 mm, noncarious mechanical or traumatic exposure under favorable conditions; biocompatible radiopaque cap and sealed restoration.
• Do not generalize this indication to carious primary-tooth exposures.

Pulpotomy

• Carious or traumatic exposure, usually normal pulp/reversible pulpitis, without infection/pathologic resorption.
• Remove coronal pulp; remaining radicular tissue must be vital, without pus/necrosis or bleeding uncontrolled after several minutes with a cotton pellet.
• Calcium silicates such as MTA/Biodentine have better pulpotomy success than other materials.
• Selected primary teeth with spontaneous pain but no infection may also qualify.
• One-year restoration comparisons do not establish long-term equivalence.

Assess primary vital-therapy success

• Success: asymptomatic vital tissue, no pathologic external/progressive internal resorption or furcation/apical disease, and no successor injury.
• Stable internal resorption after pulpotomy can be monitored; remove the tooth if perforation causes support loss or infection/inflammation.

Primary eligibility: 2024 evidence and 2026 guidance

For deep caries with normal pulp or reversible pulpitis, use selective removal/IPT without exposure; if exposure occurs and the radicular pulp is suitable, favor calcium-silicate pulpotomy. The 2024 primary VPT guideline grades these choices for that population.

• The 2026 pulpotomy section also permits calcium-silicate pulpotomy in selected primary teeth with spontaneous pain but no clinical or radiographic infection.
• Assess the remaining radicular pulp: it must be vital, without pus or necrosis, and bleeding must be controllable.
• This expands eligibility beyond the 2024 guideline, which excluded irreversible-pulpitis pain and identified spontaneous-pain VPT as a research question.
• Its 24-month GRADE ratings do not establish equivalent evidence for this newer indication.

A sinus tract, furcation/apical infection, or necrotic radicular tissue places the tooth on the nonvital/extraction pathway. Spontaneous pain alone and established infection are different findings; neither a pain-duration cutoff nor five minutes of bleeding alone establishes the diagnosis.

Decision map: primary-tooth pulp treatment

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Spontaneous pain alone is not necrosis. The 2026 best practice expands primary pulpotomy eligibility to selected spontaneous-pain cases without infection; radicular tissue must remain suitable. The 2024 normal/reversible-pulp GRADE ratings do not transfer to that expanded indication. Assess LSTR exclusions separately, especially excessive resorption, imminent exfoliation, a perforated floor, allergy, and infective-endocarditis risk.

Primary teeth: nonvital options

Pulpectomy

• Irreversible pulpitis/necrosis, including unfavorable radicular findings during planned pulpotomy; roots should have minimal/no resorption.
• Debride, disinfect, fill with resorbable material and seal.
• Reviewed irrigants showed no success difference.
• ZOE performed better long term than iodoform-based pastes in the cited review.
• Avoid gross overfill/underfill and permit normal root/filling resorption and successor eruption.
• Expect symptoms to resolve within weeks and radiographic infection to resolve with bone deposition by 6 months.

LSTR (lesion sterilization/tissue repair)

• Usually no canal instrumentation; intracoronal antibiotic paste targets canal infection.
• Source describes enlarged canal-orifice receptacles, chamber cleaning, antibiotic paste, glass-ionomer seal and preferably a stainless steel crown.
• Described antibiotics: clindamycin, metronidazole and ciprofloxacin.
• Preference for mixtures without tetracycline is conditional, very low-quality evidence; staining is another concern.
• Regimens/vehicles vary and comparative results are inconsistent.
• LSTR may be preferred over pulpectomy for a resorbing tooth intended for retention < 12 months; assess strategic value.
• Contraindications: allergy to ingredients, excessive internal/external resorption, imminent exfoliation, perforated chamber floor, or infective-endocarditis risk.
• Short intended retention does not override these exclusions.
• Monitor symptom resolution and radiographic bone repair.

Immature permanent teeth: preserve development

• Apexogenesis means continued physiologic apical development through preservation of vital pulp; it is an outcome of appropriate vital therapy.

Liner/IPT

• Normal or reversibly inflamed pulp with deep caries; protect dentin and seal.
• Selective IPT is completed without planned reentry.
• Stepwise treatment may be considered near three-quarters dentin depth: initial limited excavation/temporary seal, then removal to firm dentin/final restoration.
• Similar success is reported, but selective removal offers fewer exposures and one visit.

Direct cap

• Small carious/mechanical exposure in a normal pulp after hemorrhage control.
• Calcium silicates outperform calcium hydroxide at 36 months in the cited evidence.

Partial pulpotomy, carious

• Vital normal/reversibly inflamed pulp, including extremely deep lesions.
• Remove 1–3 mm or deeper until infected tissue is eliminated and vitality assessed; control bleeding within several minutes.

Cvek pulpotomy, traumatic

• Favored for vital complicated crown fractures, especially open apices.
• The 2026 narrative describes exposures ≤4 mm and removal 1–3 mm or more to healthy tissue.
• Its indication is a vital, traumatically exposed young permanent tooth; the exposure size is not a stand-alone exclusion rule.
• The cited literature supports treatment up to 9 days after exposure, with no outcome evidence for longer delays in that passage; day 9 is not an established absolute cutoff.
• The 2025 permanent VPT guideline favors partial/full pulpotomy over direct capping for traumatic normal/reversible-pulp exposures without setting those size/time gates.

Partial pulpotomy: material and seal

• For partial pulpotomy, calcium silicate covering is at least 1.5 mm, followed by resin-modified glass ionomer and a sealed restoration.
• Consider nonstaining, bismuth-free calcium silicates for esthetics; MTA may discolor teeth.

Complete pulpotomy

• Remove all coronal pulp, preserve radicular vitality and monitor future endodontic needs.
• May treat selected immature teeth with irreversible pulpitis or provide emergency relief before definitive root canal therapy.
• Hemostasis ≤6 minutes was associated with greater success in symptomatic irreversible pulpitis; it is a prognostic finding.

Assess permanent vital-therapy success

• Vital-therapy success includes no symptoms/pathosis, continued root development and no resorption or abnormal/accelerated canal calcification.

Permanent teeth: nonvital options

Apexification

• Necrotic tooth with incomplete roots; create root-end closure/apical barrier.
• Source describes traditional calcium-hydroxide disinfection for 2 weeks–1 month, followed by calcium silicate barrier approaches.
• A collagen matrix may help contain MTA; obturate remaining space.
• Thin walls require fracture-risk consideration.

Regenerative endodontics

• Nonvital immature roots; aim first for symptom/infection resolution, then thicker walls and possible root lengthening/apical maturation, with vitality recovery as an aim.
• May be preferred over apexification for developmental potential; growth is not guaranteed.
• Initial inflammatory resorption worsens prognosis.
• Cited moderate-quality evidence did not demonstrate a success/failure difference versus conventional root canal therapy, with case-mix limitations.

Conventional root canal therapy

• Restorable permanent tooth with closed apex and irreversible pulpitis/necrosis.
• Clean, disinfect, shape and obturate; persistent lesions, inaccessible canals or calcification may require specialized care.

Shared treatment goals

• Seek healing without resorption, fracture or support breakdown; immature teeth should continue eruption with surrounding alveolar growth.

Follow-up and evidence

• Clinical review generally every 6 months; acute infection may require earlier reassessment.
• Primary pulpectomy: immediate postoperative baseline radiograph. Nonvital primary therapies: clinical/radiographic assessment at least every 12 months.
• Primary pulpotomy: radiographs at least annually; obtain a periapical image if bitewings omit the interradicular area. Immature permanent teeth need close clinical/radiographic surveillance.
• This best practice combines trials/reviews with consensus where evidence is insufficient. Reported success percentages are context-specific, not guarantees.

Common board traps

Answer aloud

Deep caries in a symptom-free primary molar: your plan?

Use selective caries removal and indirect pulp treatment for an eligible restorable primary molar, then provide a durable coronal seal.

• Confirm normal/reversible pulp and absence of radicular disease.

• Avoid pulp exposure; routine reentry is not required when the seal and clinical course remain satisfactory.

• If exposed, assess vital radicular tissue and controllable bleeding for calcium-silicate pulpotomy.

• Spontaneous pain would require reassessing eligibility; it is not the symptom-free pathway.

Traumatic exposure in an immature incisor: your priority?

Preserve vital pulp to allow apexogenesis; assess partial (Cvek) pulpotomy for the vital traumatic exposure.

• Remove superficial inflamed tissue to reach healthy pulp and establish hemostasis.
• Use an appropriate calcium-silicate material and durable seal; consider discoloration in the anterior region.
• Monitor symptoms, periapical health, and continuing root development.
• The source’s ≤4-mm exposure and up-to-nine-day literature description are not stand-alone exclusion rules.

What are the treatment options for a necrotic permanent tooth with an open apex, and how do you choose between them?

Compare regenerative endodontics with apexification: both address infection, but regeneration offers potential additional root development.

• Apexification: creates an apical barrier; it does not continue physiologic root development.

• Regenerative endodontic treatment aims for healing and may permit further development.

• Explain prognosis, follow-up, and uncertainty about the amount and predictability of developmental improvement when comparing the options.

Does spontaneous pain automatically rule out primary-tooth pulpotomy?

No. The 2026 best practice permits calcium-silicate pulpotomy in selected primary teeth with spontaneous pain and no clinical or radiographic infection.

• Radicular pulp must be vital, without pus/necrosis, and bleeding controllable after several minutes.
• The 2024 guideline’s GRADE ratings for normal/reversible pulp do not establish equivalent evidence for this expanded indication.
• Infection or necrotic radicular tissue requires a nonvital/extraction assessment.

When might LSTR suit a primary tooth, and what excludes it?

Consider LSTR for a strategically useful resorbing tooth intended for retention less than 12 months, after applying the 2026 exclusions.

• Exclude ingredient allergy, excessive internal/external resorption, imminent exfoliation, a perforated chamber floor, or infective-endocarditis risk.
• Minimal/no root resorption favors pulpectomy when otherwise indicated.
• Arrange clinical/radiographic monitoring; short intended retention does not override a contraindication.

What follow-up is required after primary-tooth pulp treatment?

Review clinically generally every six months; assess primary pulpotomies radiographically at least annually.

• Acute infection may need earlier clinical review.
• Obtain an immediate postoperative baseline image after pulpectomy; assess nonvital primary therapies clinically/radiographically at least every 12 months.
• For pulpotomy, obtain a periapical image if a bitewing omits the interradicular area.
• Look for symptoms, resorption, furcation/apical disease, and successor harm.