Theme notesPulp therapy
Theme notesPulp therapy
Pulp therapy: choose the right tooth pathway
Keep the pulp guidelines together, but separate primary from permanent teeth. Diagnose before naming a procedure; then explain restorability, root maturity, the seal, and follow-up.
Remember
Tooth → pulp → roots → restore → review.
Key points
Use the pain history, examination, and radiographs together. Sensibility tests have limited reliability in primary and immature permanent teeth.
Pulp best practice · 2026 (PDF opens in a new tab)For deeply carious primary teeth with normal or reversible pulp, selective removal with indirect pulp treatment or calcium-silicate pulpotomy is favored; direct pulp capping has less certain evidence.
Primary vital pulp · 2024 (PDF opens in a new tab)A restorable nonvital primary tooth without significant resorption favors pulpectomy. LSTR is a conditional short-term option for selected resorbing teeth, with close monitoring.
Primary nonvital pulp (PDF opens in a new tab)- 2026 eligibility: The 2026 best practice permits calcium-silicate pulpotomy in selected spontaneous-pain cases without clinical/radiographic infection, with vital radicular tissue and controllable bleeding.
- 2024 evidence scope: The 2024 guideline excluded irreversible-pulpitis pain; its graded evidence remains limited to normal/reversible pulp.
- Exclusion: Established infection or necrosis does not qualify for this newer vital option.
In permanent teeth, spontaneous pain does not automatically exclude vital therapy. Selected vital teeth with normal periapical tissues and controlled bleeding may receive full pulpotomy.
Permanent vital pulp · 2025 (PDF opens in a new tab)Answer aloud
How should you treat deep caries without pulp exposure in a primary tooth?
With normal or reversible pulp, selective removal and indirect pulp treatment preserve vitality. If exposed and the radicular pulp is suitable, calcium-silicate pulpotomy is preferred over older agents. Finish with a durable seal.
Primary vital pulp · 2024 (PDF opens in a new tab)How should you treat a nonvital primary tooth with root resorption?
Assess restorability, roots, medical status, and retention time.
- Retention options: Intact roots favor pulpectomy; eligible resorbing teeth may receive short-term LSTR with close surveillance.
- LSTR exclusions: Excessive resorption, imminent exfoliation, floor perforation, ingredient allergy, or infective-endocarditis risk excludes LSTR.
- Extraction: Extract when retention or infection control is unsuitable.
How does treatment differ between deep and extremely deep caries in a permanent tooth?
- Dentin barrier: Normal/reversible pulp with a dentin barrier favors selective removal.
- Assess the pulp: No barrier or spontaneous, nocturnal, or lingering pain calls for exposure and pulp assessment.
- Eligibility: Full pulpotomy requires vital tissue, controlled bleeding, and no periapical infection; several recommendations are conditional.
Why should you preserve pulp vitality in an immature permanent tooth?
Vital pulp supports continued root development. For necrosis with an open apex, compare regenerative endodontics and apexification, prognosis, and referral; plan clinical and radiographic follow-up.
Pulp best practice · 2026 (PDF opens in a new tab)Decision map: retain a nonvital primary tooth?
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For a restorable nonvital primary tooth with intact roots, pulpectomy is preferred over LSTR (conditional, low certainty). With significant resorption, LSTR may retain an eligible tooth for up to 12 months; longer retention requires close monitoring. Excessive resorption, imminent exfoliation, floor perforation, ingredient allergy, or infective-endocarditis risk excludes LSTR. Consider extraction if the tooth is nonrestorable, infection cannot be arrested, or retention is unsuitable; assess the resulting space needs. This map applies after a nonvital diagnosis, not to selected vital spontaneous-pain cases.
Primary nonvital pulp (PDF opens in a new tab)Pulp best practice · 2026 (PDF opens in a new tab)Compare nonvital primary options
Scroll across to view all columns
| Option | Use when | Key limit |
|---|---|---|
| Pulpectomy | Restorable tooth with intact roots or minimal resorption | Pulpectomy over LSTR with intact roots: conditional, low certainty; fill choice evidence is very low certainty (zinc oxide/iodoform/calcium hydroxide and ZOE ranked above iodoform at 18 months) |
| LSTR (short-term retention) | Eligible resorbing tooth where short retention is useful | 12-month success 76% versus 47% for pulpectomy (conditional, moderate certainty); excluded by allergy, excessive resorption, imminent exfoliation, floor perforation, or infective-endocarditis risk |
| Extraction | Nonrestorable tooth, infection not arrested, or excessive resorption | Parent preference or cooperation may favor extraction even when restorable |
Quick decisions
When can calcium-silicate pulpotomy be considered for a primary tooth with irreversible pulpitis?
2026: selected spontaneous-pain cases, no infection, vital radicular tissue and controlled bleeding; 2024 GRADE scope remains normal/reversible pulp
What limits the reliability of pulp sensibility testing in primary and immature permanent teeth?
limited reliability in primary & immature teeth
Decision pathways
Sources
- Pulp Therapy for Primary and Immature Permanent Teeth: Indications and Objectives, Latest revision 2026; official but unformatted; follows the 2025 primary-section partial revision
- Use of Vital Pulp Therapies in Primary Teeth 2024, Published 2024; article last revision September 12, 2023
- Use of Non-Vital Pulp Therapies in Primary Teeth, Published 2020; article last revision June 13, 2020
- Guideline for Use of Vital Pulp Therapy in Permanent Teeth, Published 2025; article last revision July 20, 2025