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Special Issues
July/August 2019
Volume 40, Issue 1
Peer-Reviewed

Pulp Therapy in the Difficult Child Patient

Mark L. Cannon, DDS, MS

This pediatric patient presented with a dental history of severe and spontaneous pain due to the upper left primary molar that was sensitive to hot and cold foods, indicative of an irreversible pulpitis. The referring dentist had attempted to treat the patient but due to disruptive behavior (diagnosis of sensory processing disorder), the severe spontaneous pain, and pain to percussion the patient was referred for treatment by a pediatric dental specialist. Radiographs revealed an obvious carious exposure of the pulp, and the treatment plan formulated would likely include a pulpotomy therapy. After a lengthy discussion with the parent, the clinician proceeded with pulpal therapy and restoration of the tooth. One concern was that a normal-sized stainless-steel or zirconium crown would require substantial tooth preparation for full coverage, which would have been difficult for this apprehensive child to endure. An alternative, conservative treatment was to use TheraCal PT™ (BISCO, bisco.com) as the pulpal material and to restore the molar with a bulk-fill resin composite restorative. This approach was also beneficial in alleviating parental concern about stainless-steel crowns related to reported nickel reactivity. The parent had been instructed by their physician to not have metal restorations. Though full-coverage restorations historically have been placed following pulpal therapy mainly due to limitations of non-bonded silver amalgam materials, newer adhesives and restoratives have been highly successful functioning as final restorations.

Key Takeaways

Dual-cured, resin-modified calcium silicate-TheraCal PT is a biocompatible, calcium-releasing alkaline material for use in the pulp chamber that maintains tooth vitality, protects the dental pulpal complex, and is conducive to successful pulpal therapy for pediatric patients.

Resists breakdown and degradation-TheraCal PT has significant physical properties to reinforce a pulpally involved primary molar or anterior tooth, thus easing the requirement for full coverage of the treated dentition.

Conservative treatment-The use of a durable hydrophilic resin-modified tri-
or dicalcium silicate material such
as TheraCal PT allows for more conservative restorations.

About the Author

Mark L. Cannon, DDS, MS

Professor, Feinberg School of Medicine, Department of Otolaryngology, Division of Dentistry, Northwestern University, Evanston, Illinois; Private Practice, Long Grove, Illinois

Fig 1. Proper anesthesia is essential in the treatment of an apprehensive child. After placement of topical anesthetic (20% benzocaine gel) in the sulcus of the first molar, Single Tooth Anesthesia (Milestone Scientific, milestonescientific.com) was administered using Carbocaine® 3% (Septodont, septodontusa.com). STA is an intra-ligamentary technique that does not numb the soft tissue and provides intensive pulpal anesthesia. Auditory sounds confirm the correct periodontal ligament needle placement. The distal carious lesion was quite evident, and pulpal exposure was anticipated.

Figure 1

Fig 2. Rubber dam was then placed and the tooth properly isolated for pulpal therapy. The molars were pre-wedged, creating additional separation before preparation and to help prevent iatrogenic damage to the second molar. With pre-wedging, significant debris is often extruded; the wedge also protects the rubber dam and gingival tissues.

Figure 2

Fig 3. The molar was prepared and the caries removed. The pulp was cariously exposed as predicted by the clinical history and examination.

Figure 3

Fig 4. After removal of the coronal portion of the pulp, the pulpal remnants were removed using a slow-speed round bur, as shown, followed by a sharp spoon excavator. The hemorrhage was consistent with a diagnosis of acute irreversible pulpitis.

Figure 4

Fig 5. Hemorrhage control was achieved using a ferric sulfate gel (Viscostat™, Ultradent, ultradent.com). Cotton pellets were used to help control the bleeding by applying pressure to the pulp stumps. FIG 2. FIG 4. FIG 3. FIG 5.

Figure 5

Fig 6. All bleeding must be controlled for vital pulpal therapy. After hemostasis was obtained (Fig 5), cotton pellets dampened with 6% sodium hypochlorite (Vista Dental Products, vista-dental.com) were used to remove pulpal debris from and disinfect the pulp chamber. Thus, complete hemostasis and a clean pulp chamber were achieved, as shown here. Note the lack of bleeding. At this point, the pulp chamber could be successfully obturated with TheraCal PT.

Figure 6

Fig 7. TheraCal PT was properly placed and light-cured. The material sets in dual-cure mode, with a tack setting of a 10-second light exposure, followed by a self-cure mode. This ensures that all resin is polymerized, even when applied in bulk amounts, so there are no free monomers to cause pulpal reactivity. TheraCal PT can be used to reinforce the crown of pulpally treated molars. The restoration of the molar could now proceed.

Figure 7

Fig 8. The enamel walls and margins were etched with 32% Uni-Etch® w/ BAC (BISCO). After 30 seconds the etchant was removed by spraying it with copious amounts of water. Any excess moisture was removed with high-volume suction.

Figure 8

Fig 9. After All-Bond Universal® adhesive (BISCO) was applied and light-cured for 20 seconds, Reveal HD® Bulk composite (BISCO) was used, as shown, due to its exceptional depth of cure and impressive physical properties.

Figure 9

Fig 10. The final restoration placed with gross anatomy was accomplished using a diamond bur, as shown. After rubber dam removal the occlusion was adjusted using a carbide polishing bur.

Figure 10

Fig 11. Final restoration with rubber dam in place. The Reveal HD Bulk composite may appear slightly translucent. Its light transparency allows for complete photopolymerization. Adding a more opaque “enamel” layer eliminates the gray transparency effect.

Figure 11

Fig 12. The patient tolerated the procedures extremely well, and the parent was pleased with the results. This image was acquired at a follow-up visit later that week. The parent reported that the patient was asymptomatic, with no reports of pain or sleepless nights, and able to eat a normal diet. Follow-up radiographs will be obtained annually.

Figure 12

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