Behavior Guidance of the Pediatric Dental Patient










324 Part 3 The Primary Dentition Years: Three to Six Years
retentive,
63
so it is anticipated that their performance in children
will be similar. ere is no question that they provide a very esthetic
restoration.
e steps for preparation and placement of resin crowns are
listed in Box 22.9 and shown in Fig. 22.22. Because all the anterior
crown types have similarities in preparation and placement, noted
dierences for the veneered and ZCs are also listed in Box 22.9.
Preparation and Placement of Veneered Steel Crowns
and Zirconia Primary Crowns
Veneered SSCs for primary incisors and canines (Fig. 22.23) provide
a one-step esthetic restoration that, unlike resin-based composite
crowns or open-face crowns, can be placed in the presence of
hemorrhage without aecting the nal esthetic result.
70
ey can
be placed on teeth with little remaining tooth structure. In addition,
when moisture control is dicult and the resin crowns cannot be
placed, these crowns may oer a good alternative because they are
less sensitive to moisture.
Veneered SSCs have at least three limitations: (1) crimping is
limited primarily to the lingual surfaces, which does not allow as
close an adaptation; however, this does not appear to diminish
retention because they can be retained as well as crimped anterior
SSCs
77
; (2) each crown costs approximately $18 to $20, compared
with approximately $5 to $6 for strip crown forms, making an
inventory much more costly; and (3) if the veneer fractures, usually
replacing the crown, rather than repairing the fracture, will provide
the fastest, most esthetically pleasing result.
One study found fractures or wear of the veneer in approximately
14% of crowns,
75
with canines most likely to be aected. is
percentage is slightly less than the incidence of fractures reported
with strip crowns.
74
Parental acceptance for these crowns has also
been reported to be very high, with more than 90% of parents
reporting they were satised or very satised with their child’s
veneered crowns.
76
Zirconia primary crowns similarly cannot be crimped at all,
have a comparably high inventory cost ($18 to $22/crown), and
cannot be repaired in the mouth; however, these crowns are less
likely to fracture or chip than preveneered crowns. e most obvious
advantages of ZCs are their excellent esthetics, color stability, and
durability.
77
e preparation for both veneered steel crowns and ZCs is
very similar to that of a resin crown (see Box 22.9), except that
no facial undercut is required (although it can still be used); in
addition, the amount of reduction of all tooth surfaces needed is
considerably greater. A coarse tapered diamond bur is best for the
incisal, proximal, and facial tooth reduction, with a football diamond
1. Administer appropriate anesthesia.
2. Select the shade of resin-based composite to be used. Then place and
ligate the rubber dam.
3. Select a primary incisor celluloid crown form with a mesiodistal width
approximately equal to the tooth to be restored.
4. Remove decay with a large round bur in the low-speed handpiece. If pulp
therapy is required, do it now.
5. Reduce the incisal edge by 1.5 mm using a tapered diamond or a no.
169L bur.
6. Reduce the interproximal surfaces by 0.5–1.0 mm (Fig. 22.21). This
reduction should allow a crown form to slip over the tooth. The
interproximal walls should be parallel, and the gingival margin should
have a feather-edge.
7. Reduce the facial surface by at least 1.0 mm and the lingual surface by
at least 0.5 mm. Create a feather-edge gingival margin. Round all line
angles. Note: For preveneered and zirconia crowns, interproximal
reduction will be greater (approximately 1.5 mm), as will facial
(1–1.5 mm) and lingual reduction (0.5–1 mm).
8. Place a small undercut on the facial surface in the gingival one-third of
the tooth with a no. 330 bur or no. 35 inverted cone. When the resin
material polymerizes, engaging the undercut, this serves as a mechanical
lock. Note: This is not required for preveneered or zirconia crowns, but
also not contraindicated.
9. Trim the selected plastic crown form by cutting away excess material
gingivally with crown-and-bridge scissors, and trial t the crown form. A
properly trimmed crown form should t 1 mm below the gingival crest
and should be of comparable height to adjacent teeth. Remember that
maxillary lateral incisor crowns are usually 0.5–1.0 mm shorter than
those of central incisors. Note: Preveneered and zirconia crowns are tried
on until a crown slides passively over the preparation. If either will not
seat passively, more tooth reduction will be necessary until it does seat.
Because neither of these crowns ex when being placed onto a
preparation, they must not be forced to seat, which could lead to fracture.
10. After the celluloid crown is adequately trimmed, punch a small hole in
the lingual surface with an explorer to act as a vent for the escape of
trapped air as the crown is placed with resin onto the preparation. At this
point hemorrhage must be well controlled so as not to interfere with
bonding or esthetics. Note: If the zirconia crown has been contaminated
with blood or saliva during try-in, it should be either air abraded internally
or cleaned with a zirconia decontaminant (IvoClean, Ivoclar Vivadent,
Amherst, NY).
11. If a self-etching bonding agent is not used, etch the tooth with acid gel
for 15–20 seconds. Rinse and dry the tooth; then apply a dentin-bonding
agent to the entire tooth and polymerize. Note: This is not required for
preveneered or zirconia crowns.
12. Fill the crown form approximately two-thirds full with a resin-based
composite material, and seat onto the tooth. Excess material should ow
from the gingival margin and the vent hole. While holding the crown in
place, remove the gingival excess with an explorer. Note: Preveneered
crowns are usually cemented with a glass ionomer cement, and zirconia
crowns should be cemented with a resin-modied glass ionomer or
bioactive cement. A light-activated cement may be used with zirconia
crowns. The light will penetrate the zirconia.
13. Polymerize the material. Be certain to direct the curing light from both
the facial and lingual directions. Note: For preveneered and zirconia,
allow the cement to set and clean away all excess.
14. Remove the celluloid form by using a composite nishing bur or a curved
scalpel blade to cut the material on the lingual surface, and then peel the
form from the tooth.
15. Remove the rubber dam and evaluate the occlusion.
16. Little nishing should be required on the facial surface. A ame carbide
nishing bur can be used to nish the gingival margin should any
irregularities be noted upon tactile examination with an explorer.
A round or pear-shaped nishing bur may be used for nal contouring
of the lingual surface. Abrasive disks are used for nal polishing
of areas of the crown that require contouring. Note: For preveneered
crowns the proximal-incisal corners may be contoured slightly to
give a slightly less “boxy” appearance. Adjustments to zirconia
crowns’ occlusion or contour are extremely difcult and usually are
not attempted.
Preparation and Placement of Adhesive Resin–Based Composite Crowns (Pediatric Strip Crowns [3M
ESPE]) With Considerations for Preveneered and Zirconia Crowns
BOX 22.9

CHAPTER 22 Restorative Dentistry for the Primary Dentition 325
If a crown is tried on the tooth and it does not quite t, more
tooth reduction will be necessary to allow the crown to slide onto
the preparation so that the margins are subgingival. Neither type
of crown should be forced onto the preparation but should be
t with only nger pressure. Too much force during seating can
weaken or chip the resin veneer or break the gingival margin of
the ZCs. A snug, but passive, sleeve-like t of the crown over the
tooth is recommended.
78
Veneered crowns do not generally require
trimming, and ZCs cannot be trimmed. Crimping of veneered
crowns is minimal and limited to the lingual surface only. Veneered
crowns are best cemented with a glass ionomer cement and may
need to be held in place as it sets. ZCs are best cemented with an
RMGI or bioactive cement to maximize retention to the zirconia
surface. An important note about ZCs: It is strongly recommended
that hemorrhage and saliva be well controlled prior to cementing
a ZC. Both may interfere with the bond of the RMGI cement to
both the tooth and/or the zirconia. Although some of the zirconia
manufacturers place internal retentive grooves inside the crown for
added mechanical retention of the cement, not all do. Zirconia
that has been contaminated with blood and/or saliva may lose
much of its reactivity to bond well with cements.
79
For this reason,
one ZC company (NuSmile ZR Crowns, NuSmile) provides a
pink try-in crown that is used for tting to the prep. After the
appropriate t is determined, the try-in crown is exchanged for
a noncontaminated white crown which is lled with cement and
placed on the tooth. e try-in crown may be autoclaved and
used multiple times. If a ZC is contaminated by saliva or blood,
it should be cleaned internally by either air abrasion (sandblasting)
or the use of a cleansing agent specically for zirconia (Ivoclean,
Ivoclar Vivadent, Amherst, NY).
C
B
A
D
Figure 22.21 Full coronal coverage of primary incisors. (A) Multiple interproximal carious lesions in
primary incisors. (B) The incisors restored with adhesive resin–based composite crowns (strip crowns).
(C) Zirconia primary crowns (NuSmile ZR crowns, NuSmile, Houston, TX). (D) Preveenered crowns
(NuSmile Signature crowns). ([A] and [B] Courtesy Dr. Ari Kupietzky, Jerusalem, Israel.)
A
BC
1–1.5 mm
0.5 mm
1.0 mm
Figure 22.22 Adhesive resin–based composite crown (strip) prepara-
tion. (A) Labial view. (B) Proximal view. (C) Incisal view. The proximal slice
should be parallel to the natural external contours of the tooth. Note: The
crown preparation for the preveneered and zirconia crowns are very similar
to this, except for slightly more overall tooth reduction.
bur used to reduce the lingual surface. When preparing a tooth
for a veneered or ZC, the operator must keep in mind that the
preparation must be made to t the crown because the resin-based
composite facing is too brittle to permit additional manipulation
and the ZCs will not ex over convexities. erefore preparation
of an incisor for a veneered or ZC is an ongoing process. After the
preparation is completed, select a crown and try it on the tooth.

326 Part 3 The Primary Dentition Years: Three to Six Years
appliances. If a young child decides that he or she does not like
the appliance, he will nd a way to remove it from his mouth and
will usually discard it. Education of the parents regarding this fact
is essential before the decision to construct an appliance is made.
Another contraindication for prosthetic replacement is the presence
of an anterior deep bite.
Prosthetic appliances may be either xed or removable (Fig.
22.24), and many dierent designs are used for both. A xed
appliance will almost always be preferred to a removable appliance
in preschool children because of compliance issues. When construct-
ing either type, it is best to allow at least 6 to 8 weeks following
the tooth loss before fabrication. is allows for good healing and
gingival shrinkage. However, appliances can be placed the same
day the extractions are done, and the gingival tissue seems to heal
and adapt very well around the prosthetic appliance.
One xed appliance design is a Nance-like device, constructed
with two bands or, preferably, steel crowns on primary molars that
B
A
Figure 22.23 (A) Extensive caries in primary incisors. (B) Veneered crowns (NuSmile) restoring the four
incisors.
Nonveneered SSCs are not frequently used to restore maxillary
primary incisors because of the poor esthetics. However, they may
be used on severely decayed canines and mandibular incisors, where
esthetics is less noticeable.
Prosthetic Replacement of Primary
Anterior Teeth
Premature loss of maxillary primary incisors because of extensive
caries, trauma, or congenital absence requires consideration for
providing a prosthetic tooth replacement for the child.
80
In most
instances, prosthetic replacement of primary incisors is considered
an elective procedure. Space maintenance in this region is not
generally necessary. e most common reason for placement of a
prosthetic appliance is parental concern about esthetics.
Lack of compliance in appliance wear and care by the young
child is the greatest limitation of and contraindication for these
A
B
C
Figure 22.24 Prosthetic replacement of primary anterior teeth. (A) Edentulous space following extrac-
tion of two primary incisors. (B) Fixed prosthetic appliance replacing the two incisors in place. (C) Example
of a xed prosthetic appliance replacing four incisors. Note: Stainless steel crowns are used on the rst
primary molars as abutments. These provide better retention and durability than orthodontic bands.

CHAPTER 22 Restorative Dentistry for the Primary Dentition 327
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primary molars: an in vivo comparison of three restorative techniques.
J Clin Pediatr Dent. 2001;25(3):227–230.
17. Soncini JA, Maserejian NN, Trachtenberg F, et al. e longevity of
amalgam versus compomer/composite restorations in posterior primary
and permanent teeth. Findings from the New England Childrens
Amalgam Trial. J Am Dent Assoc. 2007;138(6):763–772.
18. Norman RD, Wright JS, Rydberg RJ, et al. A 5-year study compar-
ing a posterior composite resin and an amalgam. J Prosthet Dent.
1990;64(5):523–529.
19. Roberts MW, Folio J, Moa JP, et al. Clinical evaluation of a composite
resin system with a dental bonding agent for restoration of permanent
posterior teeth: a 3-year study. J Prosthet Dent. 1992;67:301–306.
20. Bernardo M, Luis H, Martin MD, et al. Survival and reasons for
failure of amalgams versus composite posterior restorations placed
in a randomized clinical trial. J Am Dent Assoc. 2007;138(6):
775–783.
21. Hickel R, Kaaden C, Paschos E, et al. Longevity of occlusally-stressed
restorations in posterior primary teeth. Am J Dent. 2005;18(3):
198–211.
22. Statement on posterior resin-based composites. ADA Council on
Scientic Aairs; ADA Council on Dental Benet Programs. J Am
Dent Assoc. 1998;129(11):1627–1628.
23. Posterior composite resins. Council on Dental Materials, Instruments,
and Equipment. J Am Dent Assoc. 1986;112(5):707–709.
24. Posterior composite resins: an update. Council on Dental Materials,
Instruments, and Equipment. J Am Dent Assoc. 1986;113(6):950–951.
25. Leinfelder KF, Vann WF. e use of composite resins on primary
molars. Pediatr Dent. 1982;4(1):27–31.
26. Duggal MS, Toumba KJ, Sharma NK. Clinical performance of a
compomer and amalgam for the interproximal restoration of primary
molars: a 24-month evaluation. Br Dent J. 2002;193(6):339–342.
27. Gross LC, Grien AL, Casamassimo PS. Compomers as class II
restorations in primary molars. Pediatr Dent. 2001;23(1):24–27.
28. Kramer N, Frankenberger R. Compomers in restorative therapy of
children: a literature review. Int J Paed Dent. 2007;17(1):2–9.
29. Marks LAM, Faict N, Welbury RR. Literature review: restorations
of class II cavities in the primary dentition with compomers. Eur
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30. Mass E, Gordon M, Fuks AB. Assessment of compomer proximal
restorations in primary molars: a retrospective study in children.
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31. Qvist V, Poulsen A, Teglers PT, et al. e longevity of dierent
restorations in primary teeth. Int J Paediatr Dent. 2010;20(1):1–7.
32. Croll TP, Bar-Zion Y, Segura A, et al. Clinical performance of
resin-modied glass ionomer cement restorations in primary teeth.
J Am Dent Assoc. 2001;132(8):1110–1116.
33. Donly KJ, Segura A, Kanellis M, et al. Clinical performance and
caries inhibition of resin-modied glass ionomer cement and amalgam
restorations. J Am Dent Assoc. 1999;130(10):1459–1466.
34. Hübel S, Mejàre I. Conventional versus resin-modied glass ionomer
cement for class II restorations in primary molars. A 3-year clinical
study. Int J Paediatr Dent. 2003;13(1):2–8.
35. Qvist V, Laurberg L, Poulsen A, et al. Longevity and cariostatic eects
of everyday conventional glass ionomer and amalgam restorations in
primary teeth: three-year results. J Dent Res. 1997;76:387–1396.
36. Fuks AB. e use of amalgam in pediatric dentistry: new insights
and reappraising the tradition. Pediatr Dent. 2015;37(2):125–132.
37. Simonsen RJ, Stallard RE. Sealant-restorations utilizing a dilute lled
resin: one year results. Quintessence Int. 1977;8(6):77–84.
38. Simonsen RJ. Conservation of tooth structure in restorative dentistry.
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39. Simonsen RJ. e preventive resin restoration: a minimally
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40. Houpt M, Fuks A, Eidelman E. e preventive resin (compos-
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are connected by a palatal wire to which the replacement teeth
are attached. ese prosthetic appliances can be fabricated by any
laboratory but are commercially available through some commercial
laboratories such as Space Maintainers Laboratory. is appliance
is cemented onto the molars and is not easily removed by the
child. It requires minimal adjustment.
81
e teeth can be made
to sit directly on the ridge of the edentulous space (preferred), or
acrylic gingiva can be added. Disadvantages of this appliance include
(1) possible decalcication around the bands, (2) more diculty
in home cleaning, and (3) bending of the wires with ngers or
sticky foods, which may create occlusal interferences and the need
for adjustments. Potential loosening of the bands resulting from
continual torquing of bands by the movement of the wire during
normal chewing may necessitate frequent recementation.
e removable appliance is a Hawley-like device that replaces
the teeth and uses circumferential and ball clasps on the molars.
These appliances require the most compliance of any of the
prosthetic replacements. They are not indicated in children
younger than 3 years. Clasps will need adjustment, the frequency
of which depends on the child’s handling of the appliances.
e greatest advantages of these appliances are that the appli-
ance can be removed for daily cleaning and that adjustments
are easily made by the dentist without having to remove and
recement bands.
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lining thickness on class II composite resins. Oper Dent.
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57. Lacy AM, Young DA. Modern concepts and materials for the pediatric
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58. Fuks AB. e use of amalgam in pediatric dentistry. Pediatr Dent.
2002;24(5):448–455.
59. Myers DR. Factors producing failure of class II silver amalgam restora-
tions in primary molars. ASDC J Dent Child. 1977;44(3):226–229.
60. Humphrey WP. Use of chromic steel in childrens dentistry. Dent
Surv. 1950;26:945–947.

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324 Part 3 The Primary Dentition Years: Three to Six Yearsretentive,63 so it is anticipated that their performance in children will be similar. ere is no question that they provide a very esthetic restoration.e steps for preparation and placement of resin crowns are listed in Box 22.9 and shown in Fig. 22.22. Because all the anterior crown types have similarities in preparation and placement, noted dierences for the veneered and ZCs are also listed in Box 22.9.Preparation and Placement of Veneered Steel Crowns and Zirconia Primary CrownsVeneered SSCs for primary incisors and canines (Fig. 22.23) provide a one-step esthetic restoration that, unlike resin-based composite crowns or open-face crowns, can be placed in the presence of hemorrhage without aecting the nal esthetic result.70 ey can be placed on teeth with little remaining tooth structure. In addition, when moisture control is dicult and the resin crowns cannot be placed, these crowns may oer a good alternative because they are less sensitive to moisture.Veneered SSCs have at least three limitations: (1) crimping is limited primarily to the lingual surfaces, which does not allow as close an adaptation; however, this does not appear to diminish retention because they can be retained as well as crimped anterior SSCs77; (2) each crown costs approximately $18 to $20, compared with approximately $5 to $6 for strip crown forms, making an inventory much more costly; and (3) if the veneer fractures, usually replacing the crown, rather than repairing the fracture, will provide the fastest, most esthetically pleasing result.One study found fractures or wear of the veneer in approximately 14% of crowns,75 with canines most likely to be aected. is percentage is slightly less than the incidence of fractures reported with strip crowns.74 Parental acceptance for these crowns has also been reported to be very high, with more than 90% of parents reporting they were satised or very satised with their child’s veneered crowns.76Zirconia primary crowns similarly cannot be crimped at all, have a comparably high inventory cost ($18 to $22/crown), and cannot be repaired in the mouth; however, these crowns are less likely to fracture or chip than preveneered crowns. e most obvious advantages of ZCs are their excellent esthetics, color stability, and durability.77e preparation for both veneered steel crowns and ZCs is very similar to that of a resin crown (see Box 22.9), except that no facial undercut is required (although it can still be used); in addition, the amount of reduction of all tooth surfaces needed is considerably greater. A coarse tapered diamond bur is best for the incisal, proximal, and facial tooth reduction, with a football diamond 1. Administer appropriate anesthesia.2. Select the shade of resin-based composite to be used. Then place and ligate the rubber dam.3. Select a primary incisor celluloid crown form with a mesiodistal width approximately equal to the tooth to be restored.4. Remove decay with a large round bur in the low-speed handpiece. If pulp therapy is required, do it now.5. Reduce the incisal edge by 1.5 mm using a tapered diamond or a no. 169L bur.6. Reduce the interproximal surfaces by 0.5–1.0 mm (Fig. 22.21). This reduction should allow a crown form to slip over the tooth. The interproximal walls should be parallel, and the gingival margin should have a feather-edge.7. Reduce the facial surface by at least 1.0 mm and the lingual surface by at least 0.5 mm. Create a feather-edge gingival margin. Round all line angles. Note: For preveneered and zirconia crowns, interproximal reduction will be greater (approximately 1.5 mm), as will facial (1–1.5 mm) and lingual reduction (0.5–1 mm).8. Place a small undercut on the facial surface in the gingival one-third of the tooth with a no. 330 bur or no. 35 inverted cone. When the resin material polymerizes, engaging the undercut, this serves as a mechanical lock. Note: This is not required for preveneered or zirconia crowns, but also not contraindicated.9. Trim the selected plastic crown form by cutting away excess material gingivally with crown-and-bridge scissors, and trial t the crown form. A properly trimmed crown form should t 1 mm below the gingival crest and should be of comparable height to adjacent teeth. Remember that maxillary lateral incisor crowns are usually 0.5–1.0 mm shorter than those of central incisors. Note: Preveneered and zirconia crowns are tried on until a crown slides passively over the preparation. If either will not seat passively, more tooth reduction will be necessary until it does seat. Because neither of these crowns ex when being placed onto a preparation, they must not be forced to seat, which could lead to fracture.10. After the celluloid crown is adequately trimmed, punch a small hole in the lingual surface with an explorer to act as a vent for the escape of trapped air as the crown is placed with resin onto the preparation. At this point hemorrhage must be well controlled so as not to interfere with bonding or esthetics. Note: If the zirconia crown has been contaminated with blood or saliva during try-in, it should be either air abraded internally or cleaned with a zirconia decontaminant (IvoClean, Ivoclar Vivadent, Amherst, NY).11. If a self-etching bonding agent is not used, etch the tooth with acid gel for 15–20 seconds. Rinse and dry the tooth; then apply a dentin-bonding agent to the entire tooth and polymerize. Note: This is not required for preveneered or zirconia crowns.12. Fill the crown form approximately two-thirds full with a resin-based composite material, and seat onto the tooth. Excess material should ow from the gingival margin and the vent hole. While holding the crown in place, remove the gingival excess with an explorer. Note: Preveneered crowns are usually cemented with a glass ionomer cement, and zirconia crowns should be cemented with a resin-modied glass ionomer or bioactive cement. A light-activated cement may be used with zirconia crowns. The light will penetrate the zirconia.13. Polymerize the material. Be certain to direct the curing light from both the facial and lingual directions. Note: For preveneered and zirconia, allow the cement to set and clean away all excess.14. Remove the celluloid form by using a composite nishing bur or a curved scalpel blade to cut the material on the lingual surface, and then peel the form from the tooth.15. Remove the rubber dam and evaluate the occlusion.16. Little nishing should be required on the facial surface. A ame carbide nishing bur can be used to nish the gingival margin should any irregularities be noted upon tactile examination with an explorer. A round or pear-shaped nishing bur may be used for nal contouring of the lingual surface. Abrasive disks are used for nal polishing of areas of the crown that require contouring. Note: For preveneered crowns the proximal-incisal corners may be contoured slightly to give a slightly less “boxy” appearance. Adjustments to zirconia crowns’ occlusion or contour are extremely difcult and usually are not attempted.Preparation and Placement of Adhesive Resin–Based Composite Crowns (Pediatric Strip Crowns [3M ESPE]) With Considerations for Preveneered and Zirconia Crowns• BOX 22.9 CHAPTER 22 Restorative Dentistry for the Primary Dentition 325 If a crown is tried on the tooth and it does not quite t, more tooth reduction will be necessary to allow the crown to slide onto the preparation so that the margins are subgingival. Neither type of crown should be forced onto the preparation but should be t with only nger pressure. Too much force during seating can weaken or chip the resin veneer or break the gingival margin of the ZCs. A snug, but passive, sleeve-like t of the crown over the tooth is recommended.78 Veneered crowns do not generally require trimming, and ZCs cannot be trimmed. Crimping of veneered crowns is minimal and limited to the lingual surface only. Veneered crowns are best cemented with a glass ionomer cement and may need to be held in place as it sets. ZCs are best cemented with an RMGI or bioactive cement to maximize retention to the zirconia surface. An important note about ZCs: It is strongly recommended that hemorrhage and saliva be well controlled prior to cementing a ZC. Both may interfere with the bond of the RMGI cement to both the tooth and/or the zirconia. Although some of the zirconia manufacturers place internal retentive grooves inside the crown for added mechanical retention of the cement, not all do. Zirconia that has been contaminated with blood and/or saliva may lose much of its reactivity to bond well with cements.79 For this reason, one ZC company (NuSmile ZR Crowns, NuSmile) provides a pink try-in crown that is used for tting to the prep. After the appropriate t is determined, the try-in crown is exchanged for a noncontaminated white crown which is lled with cement and placed on the tooth. e try-in crown may be autoclaved and used multiple times. If a ZC is contaminated by saliva or blood, it should be cleaned internally by either air abrasion (sandblasting) or the use of a cleansing agent specically for zirconia (Ivoclean, Ivoclar Vivadent, Amherst, NY).CBAD• Figure 22.21 Full coronal coverage of primary incisors. (A) Multiple interproximal carious lesions in primary incisors. (B) The incisors restored with adhesive resin–based composite crowns (strip crowns). (C) Zirconia primary crowns (NuSmile ZR crowns, NuSmile, Houston, TX). (D) Preveenered crowns (NuSmile Signature crowns). ([A] and [B] Courtesy Dr. Ari Kupietzky, Jerusalem, Israel.)ABC1–1.5 mm0.5 mm1.0 mm• Figure 22.22 Adhesive resin–based composite crown (strip) prepara-tion. (A) Labial view. (B) Proximal view. (C) Incisal view. The proximal slice should be parallel to the natural external contours of the tooth. Note: The crown preparation for the preveneered and zirconia crowns are very similar to this, except for slightly more overall tooth reduction. bur used to reduce the lingual surface. When preparing a tooth for a veneered or ZC, the operator must keep in mind that the preparation must be made to t the crown because the resin-based composite facing is too brittle to permit additional manipulation and the ZCs will not ex over convexities. erefore preparation of an incisor for a veneered or ZC is an ongoing process. After the preparation is completed, select a crown and try it on the tooth. 326 Part 3 The Primary Dentition Years: Three to Six Yearsappliances. If a young child decides that he or she does not like the appliance, he will nd a way to remove it from his mouth and will usually discard it. Education of the parents regarding this fact is essential before the decision to construct an appliance is made. Another contraindication for prosthetic replacement is the presence of an anterior deep bite.Prosthetic appliances may be either xed or removable (Fig. 22.24), and many dierent designs are used for both. A xed appliance will almost always be preferred to a removable appliance in preschool children because of compliance issues. When construct-ing either type, it is best to allow at least 6 to 8 weeks following the tooth loss before fabrication. is allows for good healing and gingival shrinkage. However, appliances can be placed the same day the extractions are done, and the gingival tissue seems to heal and adapt very well around the prosthetic appliance.One xed appliance design is a Nance-like device, constructed with two bands or, preferably, steel crowns on primary molars that BA• Figure 22.23 (A) Extensive caries in primary incisors. (B) Veneered crowns (NuSmile) restoring the four incisors. Nonveneered SSCs are not frequently used to restore maxillary primary incisors because of the poor esthetics. However, they may be used on severely decayed canines and mandibular incisors, where esthetics is less noticeable.Prosthetic Replacement of Primary Anterior TeethPremature loss of maxillary primary incisors because of extensive caries, trauma, or congenital absence requires consideration for providing a prosthetic tooth replacement for the child.80 In most instances, prosthetic replacement of primary incisors is considered an elective procedure. Space maintenance in this region is not generally necessary. e most common reason for placement of a prosthetic appliance is parental concern about esthetics.Lack of compliance in appliance wear and care by the young child is the greatest limitation of and contraindication for these ABC• Figure 22.24 Prosthetic replacement of primary anterior teeth. (A) Edentulous space following extrac-tion of two primary incisors. (B) Fixed prosthetic appliance replacing the two incisors in place. (C) Example of a xed prosthetic appliance replacing four incisors. Note: Stainless steel crowns are used on the rst primary molars as abutments. These provide better retention and durability than orthodontic bands. CHAPTER 22 Restorative Dentistry for the Primary Dentition 327 16. Rastelli FP, Vieira RS, Rastelli MCS. Posterior composite restorations in primary molars: an in vivo comparison of three restorative techniques. J Clin Pediatr Dent. 2001;25(3):227–230.17. Soncini JA, Maserejian NN, Trachtenberg F, et al. e longevity of amalgam versus compomer/composite restorations in posterior primary and permanent teeth. Findings from the New England Children’s Amalgam Trial. J Am Dent Assoc. 2007;138(6):763–772.18. Norman RD, Wright JS, Rydberg RJ, et al. A 5-year study compar-ing a posterior composite resin and an amalgam. J Prosthet Dent. 1990;64(5):523–529.19. Roberts MW, Folio J, Moa JP, et al. Clinical evaluation of a composite resin system with a dental bonding agent for restoration of permanent posterior teeth: a 3-year study. J Prosthet Dent. 1992;67:301–306.20. Bernardo M, Luis H, Martin MD, et al. Survival and reasons for failure of amalgams versus composite posterior restorations placed in a randomized clinical trial. J Am Dent Assoc. 2007;138(6): 775–783.21. Hickel R, Kaaden C, Paschos E, et al. Longevity of occlusally-stressed restorations in posterior primary teeth. Am J Dent. 2005;18(3): 198–211.22. Statement on posterior resin-based composites. ADA Council on Scientic Aairs; ADA Council on Dental Benet Programs. J Am Dent Assoc. 1998;129(11):1627–1628.23. Posterior composite resins. Council on Dental Materials, Instruments, and Equipment. J Am Dent Assoc. 1986;112(5):707–709.24. Posterior composite resins: an update. Council on Dental Materials, Instruments, and Equipment. J Am Dent Assoc. 1986;113(6):950–951.25. Leinfelder KF, Vann WF. e use of composite resins on primary molars. Pediatr Dent. 1982;4(1):27–31.26. Duggal MS, Toumba KJ, Sharma NK. Clinical performance of a compomer and amalgam for the interproximal restoration of primary molars: a 24-month evaluation. Br Dent J. 2002;193(6):339–342.27. Gross LC, Grien AL, Casamassimo PS. Compomers as class II restorations in primary molars. Pediatr Dent. 2001;23(1):24–27.28. Kramer N, Frankenberger R. Compomers in restorative therapy of children: a literature review. Int J Paed Dent. 2007;17(1):2–9.29. Marks LAM, Faict N, Welbury RR. Literature review: restorations of class II cavities in the primary dentition with compomers. Eur Arch Paediatr Dent. 2010;11(3):109–114.30. Mass E, Gordon M, Fuks AB. Assessment of compomer proximal restorations in primary molars: a retrospective study in children. ASDCJ Dent Child. 1999;66(2):93–97.31. Qvist V, Poulsen A, Teglers PT, et al. e longevity of dierent restorations in primary teeth. Int J Paediatr Dent. 2010;20(1):1–7.32. Croll TP, Bar-Zion Y, Segura A, et al. Clinical performance of resin-modied glass ionomer cement restorations in primary teeth. J Am Dent Assoc. 2001;132(8):1110–1116.33. Donly KJ, Segura A, Kanellis M, et al. Clinical performance and caries inhibition of resin-modied glass ionomer cement and amalgam restorations. J Am Dent Assoc. 1999;130(10):1459–1466.34. Hübel S, Mejàre I. Conventional versus resin-modied glass ionomer cement for class II restorations in primary molars. A 3-year clinical study. Int J Paediatr Dent. 2003;13(1):2–8.35. Qvist V, Laurberg L, Poulsen A, et al. Longevity and cariostatic eects of everyday conventional glass ionomer and amalgam restorations in primary teeth: three-year results. J Dent Res. 1997;76:387–1396.36. Fuks AB. e use of amalgam in pediatric dentistry: new insights and reappraising the tradition. Pediatr Dent. 2015;37(2):125–132.37. Simonsen RJ, Stallard RE. Sealant-restorations utilizing a dilute lled resin: one year results. Quintessence Int. 1977;8(6):77–84.38. Simonsen RJ. Conservation of tooth structure in restorative dentistry. Quintessence Int. 1985;16(1):15–24.39. Simonsen RJ. e preventive resin restoration: a minimally invasive, nonmetallic restoration. Compend Contin Educ Dent. 1987;8(6):428–435.40. Houpt M, Fuks A, Eidelman E. e preventive resin (compos-ite resin/sealant) restoration: nine-year results. Quintessence Int. 1994;25(3):155–159.are connected by a palatal wire to which the replacement teeth are attached. ese prosthetic appliances can be fabricated by any laboratory but are commercially available through some commercial laboratories such as Space Maintainers Laboratory. is appliance is cemented onto the molars and is not easily removed by the child. It requires minimal adjustment.81 e teeth can be made to sit directly on the ridge of the edentulous space (preferred), or acrylic gingiva can be added. Disadvantages of this appliance include (1) possible decalcication around the bands, (2) more diculty in home cleaning, and (3) bending of the wires with ngers or sticky foods, which may create occlusal interferences and the need for adjustments. Potential loosening of the bands resulting from continual torquing of bands by the movement of the wire during normal chewing may necessitate frequent recementation.e removable appliance is a Hawley-like device that replaces the teeth and uses circumferential and ball clasps on the molars. These appliances require the most compliance of any of the prosthetic replacements. They are not indicated in children younger than 3 years. Clasps will need adjustment, the frequency of which depends on the child’s handling of the appliances. e greatest advantages of these appliances are that the appli-ance can be removed for daily cleaning and that adjustments are easily made by the dentist without having to remove and recement bands.References1. Black GV. A Work on Operative Dentistry. Vol. 11. ed 5. Chicago: Medico-Dental Publishing; 1924.2. Donly KJ. Update in Pediatric Dentistry Restorative Symposium. Pediatr Dent. 2015;37(2):98.3. Bhaskar SN, Lilly GE. Intrapulpal temperature during cavity prepara-tion. J Dent Res. 1965;44(4):644–647.4. Bouschor CF, Matthews JL. A four-year clinical study of teeth restored after preparation with an air turbine handpiece with air coolant. J Prosthet Dent. 1966;16(2):306–309.5. Kupietzky A, Vargas G, Waggoner WF, et al. Use of coolant for high-speed tooth preparation: a survey of pediatric dentistry residency program directors in the United States. Pediat Dent. 2010;32(3):212–217.6. Goldstein RE, Parkins FM. Air-abrasive technology: its new role in restorative dentistry. J Am Dent Assoc. 1994;125:551–557.7. Black R. Technique for nonmechanical preparation of cavities and prophylaxis. J Am Dent Assoc. 1945;39:953–965.8. Martens LC. Laser physics and a review of laser applications in dentistry for children. Eur Arch Paediatr Dent. 2011;12(2): 61–67.9. Olivi G, Genovese MD. Laser restorative dentistry in children and adolescents. Eur Arch Paediatr Dent. 2011;12(2):68–78.10. Ganesh M, Parikh D. Chemomechanical caries removal (CMCR) agents: review and clinical application in primary teeth. J Dent Oral Hyg. 2011;3(3):34–45.11. Valachi B. Practice dentistry pain free: evidence-based strategies to prevent pain and extend your career. Portland, OR: Posturedontics; 2008:102–110.12. Leinfelder KF, Sluder TB, Santos JR, et al. Five-year clinical evaluation of anterior and posterior restorations of composite resin. Oper Dent. 1980;5:57–65.13. Donly KJ, Garcia-Godoy F. e use of resin-based composite in children: an update. Pediatr Dent. 2015;37(2):136–143.14. Cunha RF. A thirty-month clinical evaluation of a posterior composite resin in primary molars. J Clin Pediatr Dent. 2000;24(2):113–115.15. Fuks AB, Araujo FB, Osorio LB, et al. Clinical and radiographic assessment of class II esthetic restorations in primary molars. Pediatr Dent. 2000;22(6):479–485. 328 Part 3 The Primary Dentition Years: Three to Six Years61. Einwag J, Dunninger P. Stainless steel crown versus multisurface amalgam restorations: an 8-year longitudinal study. Quintessence Int. 1996;22(5):321–323.62. Seale NS, Randall R. e use of stainless steel crowns: a systematic literature review. Pediatr Dent. 2015;37(2):147–162.63. Miyazaki T, Nakamura T, Matusumura H, et al. Current status of zirconia restoration. Prosth Res. 2013;57:236–261.64. Johnson-Harris D, Chiquet B, Flaitz C, et al. Wear of primary tooth enamel by ceramic materials. 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Pediatr Dent. 2010;32(5):413–416.72. Helpin ML. e open-face steel crown restoration in children. ASDC J Dent Child. 1983;50(1):34–38.73. Kupietzky A, Waggoner WF. Parental satisfaction with bonded resin composite strip crowns for primary incisors. Pediatr Dent. 2004;26(4):337–340.74. Kupietzky A, Waggoner WF, Galea J. Long term photographic and radiographic assessment of bonded resin composite strip crowns for primary incisors: results after 3 years. Pediatr Dent. 2005;27(3): 221–225.75. MacLean JK, Champagne CE, Waggoner WF, et al. Clinical outcomes for primary anterior teeth treated with preveneered stainless steel crowns. Pediatr Dent. 2007;29(5):377–381.76. Champagne C, Waggoner W, Ditmyer M, et al. Parental satisfaction with preveneered stainless steel crowns for primary anterior teeth. Pediatr Dent. 2007;29(6):465–469.77. Waggoner WF. Restoring primary anterior teeth: updated for 2014. Pediatr Dent. 2015;37(2):163–170.78. Waggoner WF. Clinical tips for restoration of primary anterior teeth with preveneered anterior stainless steel crowns. J Pediatr Dent Care. 2003;9(3):25–29.79. Yang B, Lange-Jansen HC, Schamberg M, et al. Inuence of saliva contamination n zirconia bonding. Dent Materials. 2008;24(4):508–513.80. Steen JM, Miller JB, Johnson R. An esthetic method of anterior space maintenance. J Dent Child. 1971;38(3):154–157.81. Waggoner WF, Kupietzky A. Anterior esthetic xed appliances for the preschooler: considerations and a technique for placement. Pediatr Dent. 2001;23(2):147–150.41. dos Santos PH, Pavan S, Assunção WG, et al. Inuence of surface sealants on microleakage of composite resin restorations. J Dent Child. 2008;75(1):24–28.42. Fernández E, Martín J, Vildósola P, et al. Can repair increase the longevity of composite resins? Results of a 10-year clinical trial. J Dent. 2015;43(2):279–286.43. Moncada G, Fernández E, Martín J, et al. Increasing the longevity of restorations by minimal intervention: a two-year clinical trial. Oper Dent. 2008;33(3):258–264.44. Pereira JC, Mano AP, Franco EB, et al. Clinical evaluation of Dycal under amalgam restorations. Am J Dent. 1990;3:67–70.45. Donly KJ, Wild TW, Jensen ME. Posterior composite class II restora-tions: in vitro comparison of preparation designs and restorative techniques. Dent Mater. 1990;6:88–93.46. Dawson LR, Simon JF, Taylor PP. Use of amalgam and stainless steel restorations for primary molars. ASDC J Dent Child. 1981;48(6): 420–422.47. Randall RC. Preformed metal crowns for primary and permanent molar teeth: review of the literature. Pediatr Dent. 2002;24(5):489–500.48. Messer LB, Levering NJ. e durability of primary molar restorations: II. Observations and predictions of success of stainless steel crowns. Pediatr Dent. 1988;10(2):81–85.49. Roberts JF, Sherri M. e fate and survival of amalgam and preformed crown molar restorations placed in a specialist pediatric dental practice. Br Dent J. 1990;169(10):237–239.50. Guelmann M, Mjor IA, Jerrel GR. e teaching of class I and II restorations in primary molars: a survey of North American dental schools. Pediatr Dent. 2001;23(5):410–414.51. Leinfelder KF. A conservative approach to placing posterior composite resin restorations. J Am Dent Assoc. 1996;127(6):743–748.52. Marks LAM, Weerheijm LK, van Amerongen WE, et al. Dyract versus Tytin class II restorations in primary molars: 36 months evaluation. Caries Res. 1999;33(5):387–392.53. Marks LAM, van Amerogen WE, Kreulen CM, et al. Conservative interproximal box-only polyacid modied composite restorations in primary molars, twelve-month clinical results. ASDC J Dent Child. 1999;66(1):23–29.54. Welbury RR, Shaw AJ, Murray JJ, et al. Clinical evaluation of paired compomer and glass ionomer restorations in primary molars: nal results after 42 months. Br Dent J. 2000;189(2):93–97.55. Garcia-Godoy F. Resin-based composites and compomers in primary molars. Dent Clin North Am. 2000;44(3):541–570.56. Chuang SF, Jin YT, Chang CH, et al. Inuence of owable composite lining thickness on class II composite resins. Oper Dent. 2004;29(3):301–308.57. Lacy AM, Young DA. Modern concepts and materials for the pediatric dentist. Pediatr Dent. 1996;18(7):469–475.58. Fuks AB. e use of amalgam in pediatric dentistry. Pediatr Dent. 2002;24(5):448–455.59. Myers DR. Factors producing failure of class II silver amalgam restora-tions in primary molars. ASDC J Dent Child. 1977;44(3):226–229.60. Humphrey WP. Use of chromic steel in children’s dentistry. Dent Surv. 1950;26:945–947. CHAPTER 22 Restorative Dentistry for the Primary Dentition 328.e1 Case Study: Pediatric Zirconia CrownsCody C. HughesA 4-year, 2-month-old Hispanic male presents to the dental clinic with his mother and sibling upon referral for a new patient exam.• Chief Complaint: The patient has been experiencing pain on the lower right.• Social History: The patient lives at home with his parents and older brother. The socioeconomic status of the family is low and the patient is on government-provided insurance.• Medical History: The patient is a healthy, well-appearing child with no medical diagnosis, nor previous hospitalizations. He currently does not take medication and has no known drug allergies. The patient is ASA class I.• Dental History: The patient was seen at another dental ofce for a “check-up” and then referred to a pediatric dentist due to the treatment needs and patient’s anxiety. The patient has never had dental treatment. The parents report the patient brushes daily using uoridated toothpaste with assistance from his father, but he does not use oss.The patient is examined. No signicant ndings are noted on extraoral exam. Upon intraoral exam, soft tissue is normal; generalized, moderate plaque is visible; occlusion is mesial step molars and class I canines with 80% overbite and 2 mm of overjet; no crowding; caries are visible on all rst primary molars and upper primary incisors (Fig. E22.1A). The patient is very anxious during the exam and requires light restraint by the mother to complete the exam. The patient is given a Frankl behavior rating of 2.Upper and lower occlusal radiographs are prescribed and obtained by the dental assistant. Multiple carious lesions, as noted in the intraoral exam, are seen on the maxillary primary incisors in the upper occlusal radiograph. There is no indication of pulpal involvement (see Fig. E22.1B). Bitewings are unobtainable due to patient behavior. The patient is classied as high risk and diagnosed with severe early childhood caries.The treatment plan prescribes full coverage of all cariously involved teeth due to the size of the lesions, multiple surfaces involved, high caries risk, and poor oral hygiene of the patient. The patient is scheduled to complete treatment in the operating room under general anesthesia due to the patient’s inability to cooperate for treatment in the traditional dental setting and the extent and type of treatment required.The maxillary primary incisors are treated with full coverage zirconia crowns. The following steps were used in this case, similar to the steps outlined in Box 22.9 in the chapter.1. After the patient is prepared in the usual manner for treatment under general anesthesia, local anesthetic is administered.2. A rubber dam is placed, using a slit dam technique.3. The appropriate size of crown is selected (Fig. E22.2A).4. Teeth are prepared with reduction of surfaces as specied in Box 22.9 for zirconia crowns (see Fig. E22.2B and C).5. Crowns are checked for t and alignment (see Fig. E22.2D).6. Hemorrhage is controlled, and the crowns are cemented using resin-modied glass ionomer cement (see Fig. E22.2E).7. Occlusion is veried (see Fig. E22.2F).Questions1. What factors are used to determine if a patient is high risk for caries?Answer:• Mother/primary caregiver has active cavities.• Parent/caregiver has low socioeconomic status.• Child has more than 3 between meal sugar-containing snacks or beverages per day.• Child is put to bed with a bottle containing natural or added sugar.• Child has special health care needs.• Child is a recent immigrant.• Child has white spot lesions or enamel defects.• Child has visible cavities or llings.• Child has plaque on teeth.• Child has elevated mutans streptococci levels.• Patient has low salivary ow.12. What are indications for full coverage restoration of primary incisors?Answer: Incisors with (1) large interproximal lesions, or large lesions covering a single surface (e.g., lingual surfaces in nursing caries); (2) small interproximal lesions that also demonstrate large areas of cervical decalcication (i.e., high caries risk); (3) multiple hypoplastic defects or developmental disturbances; or (4) discoloration that is unesthetic.Incisors that have received pulp therapy and incisors that have been fractured and have lost an appreciable amount of tooth structure.BA• Figure E22.1 (A) Decayed anterior maxillary primary teeth. (B) Maxillary occlusal radiograph to check for possible pulpal involvement. Continued 328.e2 Part 3 The Primary Dentition Years: Three to Six YearsGECFDBA• Figure E22.2 (A) Appropriate size crowns selected. (B) Tooth reduction for zirconium crowns. (C) Tooth reduction for zirconium crowns completed. (D) Crowns are checked for t and alignment. (E) Crowns are cemented. (F and G) Crown restorations completed. CHAPTER 22 Restorative Dentistry for the Primary Dentition 328.e3 3. What considerations should be given when deciding on the type of full coverage restoration for primary incisors?Answer:• Size of carious lesion(s)/amount of tooth structure remaining after caries removal• Ability to achieve isolation/hemorrhage control• Esthetics• Patient occlusion; is there a deep bite or signicant wear of the incisors?• Crowding/spacing of the incisors• Insurance coverage or nancial consideration for the patient4. When restoring primary incisors with zirconia crowns, how much tooth reduction is required for the incisal, interproximal, facial, and lingual surfaces?Answer:• Incisal, 1 to 1.5 mm• Interproximal, 1 to 1.5 mm• Facial, 1.0 mm• Lingual, 0.5 to 1.0 mm, removing cingulum5. What types of cement are considered clinically acceptable for preformed zirconia crowns on primary teeth?Answer: Resin-modied glass ionomer, bioactive cement such as Ceramir or Biocem, or resin cement.Reference1. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent. 2016;38(6):142–149. 32923 Pulp Therapy for the Primary DentitionANNA B. FUKS, ARI KUPIETZKY, AND MARCIO GUELMANNCHAPTER OUTLINEHistologyThe Pulp-Dentin ComplexDentinogenesis in Healthy StateDentinogenic Response to InjuryFactors Aecting Dentin-Pulp Complex Response to Stimuli in Primary TeethClinical Pulpal DiagnosisMedical HistoryExtra- and Intraoral ExaminationPain CharacteristicsSensibility TestsPreoperative Diagnosis of Deep Caries LesionsOperative DiagnosisTraumaCorrelation Between Histopathologic Status of the Pulp and Deep CariesPulp Treatment ProceduresVital Pulp Therapy for Normal Pulp/Reversible PulpitisSummarye odontoblasts are cells responsible for the synthesis and deposition of the collagen-rich dentin organic matrix, which is further mineralized around the pulp tissue. erefore dentin and the pulp remain closely associated during tooth development throughout life and are commonly referred as the dentin-pulp complex. e odontoblasts line the periphery of the pulp space and extend their cytoplasmic processes into the dentinal tubules. ese cells have several junctions, which allow intercellular com-munication and help maintain the relative position of one cell to another. Below the odontoblastic layer is the cell-free zone that contains an extensive plexus of unmyelinated nerves and blood capillaries. e large blood vessels and nerves are located in the core of the pulp and are surrounded by loose connective tissue.2,3 Although this description is correct during active dentinogenesis, it is now accepted that the size of the odontoblasts and the content of their cytoplasmic organelles vary throughout their life cycle and are closely related to their functional activity. e relationship between the size of the odontoblasts and their secretory activity can be demonstrated by dierences in their size in the crown and in the root and may express dierent dentinogenic rates in these two areas of the tooth.4e odontoblasts are highly specialized cells that extend cyto-plasmic processes into the dentinal tubules, where they contribute to the main part of the pulp-dentin complex. When this complex is damaged by injury (disease or operative procedures), it reacts in an attempt to defend the pulp.The Pulp-Dentin ComplexDentinogenesis in Healthy Statee inner enamel epithelium and its associated basement membrane have an important role in direct odontoblastic cytodierentiation. ey present bioactive molecules, including growth factors immo-bilized on the basement membrane that send signals to the cells of the dental papilla, inducing the dierentiation of the ectomes-enchymal cells into odontoblasts.3 ese cells express specic gene products that will form the highly mineralized extracellular matrix of dentin. Hydroxyapatite forms the main inorganic part of dentin, whereas the organic components consist mostly of type I collagen.5 During the postmitotic state, the odontoblasts line the formative surface of the matrix and start secreting primary dentin. At the initiation of dentinogenesis, during mantle dentin formation, mineralization is achieved through the mediation of matrix vesicles. Mantle dentin is the rst dentin to be formed, has an approximate thickness of 80 to 100 µm, and is almost free of developmental defects.2Maintaining the integrity and health of the oral tissues is the primary objective of pulp treatment. Premature loss of primary teeth can lead to malocclusion and esthetic, phonetic, and functional problems; these in turn may be transient or permanent. It is important to attempt to preserve pulp vitality whenever possible; however, when this is not feasible, the pulp can be entirely eliminated without signicantly compromising the function of the tooth.1,2is chapter provides a concise review of the normal histologic characteristics of the primary pulp, and describes briey the dentinogenesis process and the factors aecting the dentin-pulp complex response to stimuli. Finally, it discusses the biological basis and rationale for the various modalities of pulpal treatment for the primary dentition.Histologye pulp of a primary tooth is histologically similar to that of a permanent tooth. e dental pulp is a specialized connective tissue of mesenchymal origin surrounded by tubular dentin walls occupy-ing the pulp chamber and the root canal. 330 Part 3 The Primary Dentition Years: Three to Six Yearspulp, a new generation of odontoblast-like cells may dierentiate from underlying pulp cells, secreting a reparative dentin matrix. Since this dentin is formed by a new generation of cells, there will be discontinuity in the tubular structure, with a subsequent reduc-tion in permeability (see Fig. 23.1B).11A critical question concerns the factors responsible for triggering the stimulation of odontoblastic activity. Although there is still much to learn regarding the molecular control of cell activity in general, and of odontoblastic activity in particular, one family of growth factors, the transforming growth factors (e.g., TGF-β) superfamily, has been reported to have extensive eects on the mesenchymal cells of many connective tissues.12During tooth development, the odontoblasts secrete TGF-β, and some remain sequestrated in the dentin matrix. e sequestrated TGF-β may be released during any process leading to tissue dis-solution, like dental caries formation or the use of acid etching, for example. us dentin matrix should be considered not as an inert dental hard tissue but rather as a potential tissue store of a cocktail of bioactive molecules (particularly growth factors) waiting to be released, if appropriate tissue conditions prevail.2,3In contrast to reactionary responses, reparative dentinogenesis represents a more complex sequence of biological processes. e migration and dierentiation of pulpal progenitor cells must take place, creating a new generation of odontoblast-like cells, before matrix secretion. A series of stereotypic wound-healing reactions occurs in the pulpal connective tissue, including vascular and cellular inammatory reactions. In vitro and in vivo experiments on reparative odontogenesis demonstrate that the noninamed pulp constitutes an appropriate environment where competent pulp cells (potential preodontoblasts) can differentiate into new odontoblast-like cells, forming reparative dentin.13,14Factors Aecting Dentin-Pulp Complex Response to Stimuli in Primary TeethAlthough the life span of the primary teeth is shorter and the dentin is thinner when compared with permanent teeth, the dentin-pulp complex response to dental caries in human primary teeth is similar to that of permanent teeth, including a reduction in the number of the odontoblasts and an increase in the number of inammatory cells. ese are found under the very deep lesions and are less numerous at more distant regions, being almost absent in the radicular apical pulp.15e primary dentition is frequently subjected to stimuli such as trauma or caries with associated pulp inammation.16 e same When mantle dentin formation is completed and the odonto-blasts form a tightly packed layer of cells, the matrix of dentin is produced exclusively by the odontoblasts. Although the other cells of the pulp (in the subodontoblastic layer and in the pulp core) support dentinogenesis, they do not have a direct role in primary dentin secretion.6,7 As the matrix is secreted, the odontoblasts move pulpally, leaving a single cytoplasmic process embedded in a dentinal tubule in the matrix. ese tubules, which increase in density near the pulp, confer the property of permeability on the dentin, a feature that has signicant clinical importance.4After secretion of the bulk of dentin during primary dentino-genesis, physiologic secondary dentin is secreted at a much slower rate throughout the life of the tooth, leading to a slow reduction in the size of the pulp chamber.8 e original postmitotic odon-toblasts, responsible for primary dentinogenesis, survive for the life of the tooth, unless subjected to injury. ese cells remain in a resting stage after primary dentinogenesis, and the physiologic secondary dentin formation represents a basal level of cell activity in the resting tooth stage.4Dentinogenic Response to InjuryIn pathologic conditions, such as in mild carious lesions or traumatic injuries, the secretory activity of the odontoblasts is stimulated to elaborate tertiary dentin. is will lead to focal secretion of new matrix at the pulp-dentin interface and possibly within the tubules, contributing to the histologic appearance of dentinal sclerosis at the injury site and to a decrease in dentin permeability.3,9 us the formation of tertiary dentin is much faster than the physiologic secondary dentin formation, so this tertiary deposition is regarded as an important defense mechanism of the pulp-dentin complex in response to either pathologic or physiologic insults (attrition).e nature and quality of the tertiary dentin depend on its tubular structure and inuence the dentin permeability of the area. us, in case of a mild injury, the odontoblasts responsible for the primary odontogenesis can frequently survive the challenge and are stimulated to secrete reactionary dentin beneath the injury site.10 Because the original odontoblasts are responsible for this matrix secretion, there will be tubular continuity and communica-tion with the primary dentin matrix (Fig. 23.1A).9 Reactionary dentin might be considered an extension of physiologic dentino-genesis. However, since it is a pathologic response to injury, it should be regarded as distinct from the primary and secondary dentinogenesis. When the injury is severe, the odontoblasts beneath the injury may die; however, if suitable conditions exist in the AB• Figure 23.1 (A) Histologic section showing tubular continuity in reactionary dentin. (B) Histologic section showing lack of continuity in the reparative dentin. (Courtesy Carlos Alberto S. Costa, DMD, PhD.) CHAPTER 23 Pulp Therapy for the Primary Dentition 331 [BMP-2]) liberated from the dentin during demineralization (see Fig. 23.1A).24,252. Carious lesion progression implies a deep cavity preparation (RDT less than 500 µm): ese lesions may lead to partial odontoblast disintegration. Depending on the pulpal inam-matory state, progenitor/stem cells can migrate to the injury site and dierentiate to yield a new generation of odontoblast-like cells. ese cells are responsible for the deposition of a specic type of tertiary dentin termed reparative dentin (see Fig. 23.1B).26,273. During a subsequent restorative process, deep cavity preparations with RDTs between 250 and 40 µm lead to poor tertiary dentin repair activity.19 is results from impaired odontoblast dentin secretory activity due to cellular injury.28 Murray et al. dem-onstrated that the mean number of intact odontoblasts found beneath this kind of cavity preparation was 36% lower than the number found beneath similar preparations with an RDT between 500 and 250 µm. is inability of odontoblasts to provide adequate pulpal repair and pulpal protection after deep cavity cutting has been supported by observations of a persistent inammatory pulpal response and odontoblast displacement following cavity cutting.28Clinical Pulpal DiagnosisCurrently, very little or no correlation exists between clinical diagnostic ndings and the histopathologic status of the pulp.29 Technologically advanced tests and tools to indicate the vitality condition of the pulp, such as laser Doppler owmetry and pulse oximetry, are available. However, when providing dental care for very young children and/or patients with special health care needs, these technologies may lead to unreliable responses, due to potential lack of cooperation.Comprehensive medical history, thorough extra- and intraoral examinations, pain characteristics, and sensibility tests comple-mented by selected radiographs will provide the clinician with essential information regarding the pulp status of a particular tooth or teeth in question. In addition, the source of the discomfort (e.g., trauma or caries, the presence of large, deep, or failed restora-tions) also plays a critical role in pulpal diagnosis and, subsequently, on the prognosis of the treatment to be provided.Medical HistoryWhen treating a medically compromised child, a more careful approach should be taken.30 Despite the lack of evidence, for severely immunocompromised patients, the American Academy of Pediatric Dentistry (AAPD) recommends cautious considerations when treating deep carious lesions with close proximity to the pulp. The risk of potential infections, which might be life threatening, drives most clinicians to consider a more radical approach, such as extraction, rather than a more conservative treatment option to preserve the tooth in the arch. In these cases, when pulpally treated teeth are present, close monitoring for signs of pulp degeneration is recommended.31Extra- and Intraoral Examinatione presence of extraoral facial swelling, redness, and/or subman-dibular lymphadenopathy may indicate the presence of an acute dentoalveolar abscess. In severe situations, facial cellulitis may involve the infraorbital space, resulting in partial/total closure of factors aect the dentin pulp responses in both primary and permanent teeth to external stimuli.The Deleterious Eects of Bacterial Inltration at the Restorative Materials MarginsA signicant number of studies have implicated the presence of bacteria and their products as responsible for the induction of the most severe forms of pulpal inammation.e involvement of bacteria in the inammatory reaction was demonstrated by the spontaneous healing of pulp exposures in germ-free animals17 and cavity surfaces that were sealed with zinc oxide–eugenol (ZOE) cement to prevent any bacterial contamina-tion.18 e presence of bacteria in cavities with a remaining dentin thickness (RDT) less than 0.25 mm stimulates more severe pulp inammatory reaction than in similar cavity preparations in the absence of bacteria.19 us the presence of bacteria always increases the mean grade of pulpal inammation, regardless of the RDT.20 ese authors also observed that the presence of bacteria in class V cavities resulted in a signicant decrease in the number of odontoblasts per unit area; this eect was more pronounced in deep cavities with RDT less than 0.5 mm than cavities with RDT greater than 0.5 mm. One can conclude that the ability to maintain an eective seal to protect the pulp from recurrent injury resulting from bacterial microleakage is a decisive factor in the clinical success of restorative products.21However, some studies have shown pulpal inammation in the absence of bacteria,22 clearly indicating that other factors are also responsible, even to a lesser extent, for pulp injury after restorative treatment.The Protective Role of the Remaining Dentin ThicknessIn vivo, the cavity RDT was found to be an important factor mediating pulpal inammatory activity, particularly when the RDT was reduced below 0.25 mm.19 In class V cavities prepared in human teeth, the protective tertiary dentin area increased with decreasing RDT until 0.25 mm.19 With an RDT below 0.25 mm, a signicant decrease in the number of odontoblasts was observed together with minimal reactionary dentin repair.23 e RDT signicantly modies the pulpal response: the thicker the RDT, the lower the pulpal reaction.17 e presence of an RDT over 500 µm (0.5 mm) delays the diusion of noxious materials to the dental pulp and allows the odontoblasts to secrete a reactionary dentin, increasing the total distance between the restorative material and the pulp. Any additional decrease in the dentin thickness below 500 µm results in a signicant reduction in the number of odontoblasts. e dierentiation of odontoblast-like cells from progenitor pulp cells, which migrate to the injury site and secrete reparative dentin, may compensate for this reduction. is reparative dentin decreases the dentin permeability and increases the distance between the restorative material and the pulp, protecting it from noxious products. us the RDT appears to provide an important protective barrier against bacterial inltration, toxins, or any noxious material applied onto the dentin.Based on the RDT, three situations can be considered:1. Initial carious lesions are present or cavity preparation is shallow (RDT greater than 500 µm): A localized reactionary dentin is secreted facing the restoration site and intratubular mineralization occurs, resulting in pulp protection by signicantly decreasing dentin permeability. It has been suggested that this stimulation may be due to signaling molecules (e.g., transforming growth factors of the β family [TGF-β1], bone morphogenetic protein-2 332 Part 3 The Primary Dentition Years: Three to Six Yearsradiographic image(s) will lead the clinician to treatment options such as pulpectomy or extraction (Fig. 23.5A and B).Sensibility TestsSensibility tests, sometimes called vitality or pulp tests, such as thermal and electric pulp test (EPT), are valuable diagnostic aids in endodontics. However, sensibility and percussion tests are not indicated in primary teeth, due to inconsistent results.33 Younger patients may also be more anxious and less reliable because of the subjective nature of the test.34 To avoid disruptive behavior, when performing percussion and palpation tests in young children, the tip of the nger should be gently used in combination with the tell-show-do (TSD) technique.1 e clinician should start the test with a contralateral nonaected tooth to familiarize the patient with a normal response to the stimuli.Preoperative Diagnosis of Deep Caries LesionsWhen facing deep carious lesions (Fig. 23.10) affecting the primary dentition, limitations exist regarding the determination of the vitality status of the pulp. Percussion and palpations tests, combined with bitewing and selected periapical radiographs, are complementary information that must be obtained. Good quality bitewing radiographs showing the furcation area clearly are essential for an accurate diagnosis. However, in young children in primary and early mixed dentition, especially when using size #0 or #1 lms, visibility of the apical third of the primary molar roots and the apical formation of rst permanent molars is not always possible. In the eye, limited mouth opening, fever, and malaise. Hospital admission for intravenous antibiotics may be necessary (Figs. 23.2A–C and 23.3A–C). Careful intraoral and radiographic examination seeking teeth with deep carious lesions or deep restora-tions must be performed. Diagnosis of pulp necrosis is then reached, and the treatment decision of extraction or root canal therapy is based on the restorability of the tooth, the severity of the infection, assessment of bone loss, lesion proximity to the succedaneous tooth follicle, and patient cooperation.32When examining hard tissues, teeth with questionable diagnoses should be evaluated for abnormal mobility and sensitivity to percus-sion. e presence of open proximal carious lesions between adjacent teeth creates a space that can serve as a reservoir causing food impaction, providing false-positive response to percussion test (inammation of interdental papilla rather than acute pulpal inammation) (Fig. 23.4A and B).Pain CharacteristicsYoung children are not good historians. For this group, parents are better prepared to report existing symptoms. Stimuli-related responses that cease when the insult is removed (provoked or elicited pain) generally indicate a favorable, reversible status of the pulp that could lead to a more conservative treatment approach such as indirect pulp therapy (IPT) or pulpotomy. Complaints of persistent, lingering, or throbbing pain, disturbing sleep and prevent-ing regular activity, are generally referred to as “spontaneous pain.” is most probably indicates an irreversible status of the pulp. e information in combination with clinical examination and CBA• Figure 23.2 (A) Six-year-old male with facial swelling caused by deep carious lesion and infection involving tooth #K. (B) Lateral view of same patient, showing redness and extent of cellulitis. (C) Periapical radiograph taken prior to extraction of the affecting tooth. CHAPTER 23 Pulp Therapy for the Primary Dentition 333 the pulp horn can also play an important role when determining if a conservative approach such as IPT is recommended.35 A clinical attempt to possibly assess the pulpal diagnosis status of deep caries lesions aecting primary molars using interim therapeutic restora-tions has been advocated.36 For asymptomatic teeth or teeth with reversible pulpal inammation, to preserve dental structures and avoid further damage to the pulp, conservative approaches such as stepwise excavation and incomplete caries removal should be considered.37 Stepwise excavation is a two-step, complete caries these situations, a periapical radiograph should be obtained to rule out the presence of internal resorption or periapical involvement.Integrity and continuity of the lamina dura, together with the presence of trabecular bone in the bifurcation area of primary molars, are indicative signs of a vital pulp. Due to anatomical dierences and the superposition of images, clear visualizations of these structures may be dicult to obtain in the maxillary arch.30 In asymptomatic primary teeth, the amount of sound dentin (at least 1.0 mm) separating the deepest layer of the caries lesion and CBA• Figure 23.3 (A) Five-year-old male with facial swelling caused by a primary maxillary tooth. Note swell-ing involving the left eye. (B) Clinical view of grossly decayed teeth #I and #J. (C) Periapical radiograph of affected teeth. Extraction of #I and #J was the treatment of choice to resolve the infection. (Courtesy Abi Adewumi, BDS, FDSRCS [Eng].)A B• Figure 23.4 (A) Mandibular rst and second primary molars with extensive caries and alveolar bone resorption due to food impaction. The history of spontaneous pain associated with tenderness to percus-sion may suggest pulp involvement. (B) The same teeth after restoration of the contact point with a stainless steel crown and an amalgam lling. The symptoms disappeared and bone regeneration is evident. (Courtesy Diana Ram, DDS.) 334 Part 3 The Primary Dentition Years: Three to Six Yearsremoval technique, with the goal of preventing pulp exposure.38 Incomplete caries removal or selective removal of soft dentin follows the same conservative concept; however, the main dierence implies leaving a layer of soft dentin at the pulpal/axial wall followed by a denitive, leakage-free restoration placed at the same appoint-ment.39 e goal is to prevent bacteria penetration and caries progression from occurring, which could lead to treatment failure (Fig. 23.6A and B). A more detailed explanation is discussed later in the “Vital Pulp erapy for Normal Pulp/Reversible Pulpitis” section.Operative Diagnosisere are instances when a nal diagnosis can only be achieved by direct evaluation of the pulp tissue, and a decision about treat-ment is made accordingly. e quality (color) and the amount of bleeding from a direct exposure of the pulp tissue must be assessed; profuse bleeding or purulent exudate indicates irreversible pulpitis or pulpal necrosis. Based on these observations, the treatment plan may be conrmed or changed. For example, if a formocresol pulpotomy is planned, the nature of the bleeding from the amputa-tion site should be normal (red color and hemostasis evident in less than 5 minutes with mild cotton pellet pressure). If bleeding persists, a more radical treatment should be undertaken (pulpectomy or extraction). Excessive bleeding is an indication that the inam-mation has reached the radicular pulp. Conversely, if a pulp polyp is present and bleeding stops normally after coronal pulp amputa-tion, a pulpotomy may be performed instead of a more radical procedure (Fig. 23.7A–E).40 Direct pulp capping (DPC) of carious BA• Figure 23.5 (A) Healthy 6-year-old patient with history of spontaneous pain for 2 days pointing to tooth #T. (B) Upon opening, tooth found to be necrotic. Root canal treatment with Vitapex paste performed, followed by a nal restoration. (Courtesy Rosa Barnes, DDS.)BA• Figure 23.6 (A) Asymptomatic tooth #L selected for indirect pulp treatment. (B) Inadequate stainless steel crown coverage resulted in treatment failure after 1-year. (Courtesy Shawn Hanway, DMD.)AB CDE• Figure 23.7 (A) First and second primary molars with extensive caries. (B) Pulp exposure after complete caries removal. (C) Extensive bleeding after pulp amputation; the color of the blood is bright red. (D) Bleeding stopped, indicating the tooth is appropriate for a pulpotomy. (E) The pulp stumps are covered with a zinc oxide–eugenol paste. (Courtesy Nathan Rozenfarb, DMD.) CHAPTER 23 Pulp Therapy for the Primary Dentition 335 colors are the most commonly found sequelae of traumatic injuries. Periapical radiographs will aid in the diagnosis and determination of treatment if needed. Teeth diagnosed with pulp canal obliteration (yellowish) are vital and should be periodically monitored.Teeth with light/dark gray discoloration may or may not be necrotic. If asymptomatic with no signs of soft tissue and/or periapical pathology, teeth should be only monitored.41 e presence of a sinus tract in combination with grayish discoloration of the tooth is a pathognomonic of pulp necrosis (Fig. 23.9).Correlation Between Histopathologic Status of the Pulp and Deep CariesIn primary teeth, very few studies investigated the correlation between caries depth and the degree of pulpal inammation. Eidelman and Ulmansky42 assessed the histologic appearance of the pulp of decayed, extracted, nonrestorable primary incisors aected by early childhood caries. Caries removal was performed, which may or may not have resulted in pulp exposures. When pulp exposure did not occur, pulps were more likely to be normal. It was concluded that the absence of pulp exposure could be a good indicator of a normal histologic status of the pulp. In cases when the pulp was exposed, most teeth had inammation conned to the coronal pulp and were considered good candidates for pulpotomy. Kassa et al.43 investigated the pulp inammation status of extracted primary molars with occlusal and proximal caries. ey found that when decay extended to more than 50% of dentin thickness, more extensive pulpal inammation was noted for proximal caries lesions than for occlusal ones with similar depth.Integration of the gathered clinical and radiographic information will give the clinician a direction to achieve the most accurate diagnosis possible. Clinical pulpal diagnosis continues to be a eld exposed primary teeth is not recommended, due to questionable prognosis.31A schematic diagram for pulpal diagnosis in primary teeth aected by deep carious lesions is presented in Fig. 23.8.TraumaTraumatic injuries to the primary dentition can have an impact on the vitality status of the pulp. Discoloration of the crown may indicate internal changes in the pulp canal. Yellow and grayish Pain history:Pulp status:Asymptomatic/elicited/provoked(possibly reversible)Spontaneous(possibly irreversible)No pulp test performed(nonreliable)Clinical evaluationSinus tract, swelling, abnormal mobility, sensitivity to percussion+Radiographic evaluationFurcation radiolucency, bone loss, periapical lesionAbsent Present(reversible status)IPT or pulpotomy(irreversible status)Pulpectomy or extraction• Figure 23.8 Pulpal diagnosis tree for deep carious lesions in primary teeth. IPT, Indirect pulp therapy. • Figure 23.9 Luxation injury affecting tooth #F resulted in grayish dis-coloration and pulp necrosis with sinus tract. 336 Part 3 The Primary Dentition Years: Three to Six Yearsand root lling). When the infection cannot be arrested by any of the methods listed, bony support cannot be regained, and the tooth is not restorable, extraction is the treatment of choice (see Fig. 23.8).Vital Pulp Therapy for Normal Pulp/Reversible PulpitisComplete removal of all carious tissue followed by “exten-sion for prevention” to place the margins of the restoration in areas less vulnerable to caries was considered the gold standard 150 years ago.39 A paradigm shift in carious lesions treatment has occurred, and in 1997 Fusyama44 suggested that in the supercial layer, grossly denaturated infected dentin should be where more investigation is needed to develop conclusive tests to help the clinician with accurate decision-making.Pulp Treatment Procedurese most important and also the most dicult aspect of pulp therapy is determining the health of the pulp or its stage of inam-mation so that an appropriate decision can be made regarding the best form of treatment. Dierent pulp treatment modalities have been recommended for primary teeth. ey can be classied into two categories: vital pulp therapy for primary teeth diagnosed with a normal pulp or reversible pulpitis (pulp protection, IPT, DPC and pulpotomy) and nonvital pulp therapy for primary teeth diagnosed with irreversible pulpitis or necrotic pulp (pulpectomy ECDBA• Figure 23.10 (A) Bitewing radiograph showing deep carious lesion affecting asymptomatic tooth #K. (B) Incomplete caries removal on the pulpal oor (tooth #K) leaving peripheral cavity walls caries-free. (C) Cavity preparations ready to be restored. (D) Resin-modied glass ionomer placed on pulpal oor as protective base. (E) Final restorations. (Courtesy Ary Kupietzky, DMD, MS.) CHAPTER 23 Pulp Therapy for the Primary Dentition 337 Selective removal to rm dentin leaves leathery dentin pulpally, while the cavity margins are left hard after removal. is is the treatment of choice for both dentitions in shallow or moderately cavitated dentinal lesions (radiographically extending less than the pulpal third or quarter of dentin).Selective removal to soft dentin is recommended in deep cavitated lesions (radiographically extending into the pulpal third or quarter of dentin). Soft carious tissue is left over the pulp to avoid exposure and further injury to the pulp, while peripheral enamel and dentin are prepared to hard dentin to allow a tight seal and a durable restoration. Selective removal to soft dentin reduces the risk of pulp exposure signicantly when compared with nonselective removal to hard or selective removal to rm dentin.Stepwise removal is carious tissue removal in two stages. Soft carious tissue is left over the pulp on the rst step, and the tooth is sealed with a provisional restoration that should be durable to last up to 12 months to allow changes in the dentin and pulp to take place. In reentering, after removing the restoration, as the dentin is drier and harder, caries removal is continued. ere is some evidence that in such deep lesions the second step might be omitted, as it increases the risk of pulp exposure.52,53e second step also adds additional cost, time, and discomfort for the patient; there is also enough evidence that it is not considered necessary for primary teeth, and selective removal to soft dentin should be carried out.53Protective BaseGuidelines published by the AAPD recommend placement of a protective base or liner on the pulpal and axial walls of a cavity preparation to act as a protective barrier between the restorative material and the tooth.31 Dentin is permeable and allows the movement of materials from the oral cavity to the pulp and vice versa. It was believed for several years that pulp inammation was caused by the toxic eects from dental materials.54 However, there is sucient evidence to show that pulpal inammation resulting from dental materials is mild and transitory, with adverse reactions occurring as the result of pulpal invasion by bacteria or their toxins.18,19,55 Continued marginal leakage with secondary recurrent caries is probably the most common cause of pulp degeneration under restorations. In deep cavities, the dentin covering the pulp is thin, and the tubules are large in diameter and packed closely together. is dentin is extremely permeable and should be covered with a material that seals dentin well, usually glass ionomer cement.56e materials most recently used as cavity sealers are those that have demonstrated multisubstrate bonding ability to bond the restorative material to the tooth. ese include resin cements, glass ionomers, and dentin-bonding agents. e benets of using these materials to bond composite to tooth structure is a well-documented and accepted procedure.56 However, employing them with amalgam is more controversial. Mahler and colleagues57 observed no dierence between amalgam restorations placed with and without bonding after 2 years, and concluded that the use of bonding agents under traditional amalgam llings should not be recommended. us protective liners or bases should only be placed in deep cavities approach-ing the pulp.Indirect Pulp Treatment (Selective Removal to Soft Dentin)IPT is recommended for teeth that have deep carious lesions approximating the pulp but have no signs or symptoms of pulp degeneration. In this procedure, the deepest layer of the remaining removed, while in the underlying layer, partially demineralized caries-aected dentin (containing intact, undenaturated collagen fibrils amenable to remineralize) should be preserved during caries excavation.45,46 ese terms are now considered outdated, particularly the term infected, which conveys the idea that dental caries is an infectious or communicable disease that needs to be cured by removing bacteria.47 Presently, managing a carious lesion includes several options, from the complete surgical excision, where no visible carious tissue is left prior to placement of the restoration, to the opposite extreme, where no caries is removed and noninvasive methods are used to prevent progression of the lesion.48,49A group of cariology experts from 12 countries met in 2015 (the International Caries Consensus Collaboration—ICCC) to discuss issues of relevance to cariology researchers, dental educators, and the clinical dentistry community.39In describing the clinical manifestation of caries, these experts agreed that it would be ideal to relate the visual, clinical appearance of the lesion directly to what is taking place histopathologically.50,51 Although this is not so straightforward, histopathologic investiga-tions of the relationship between the visual appearance of the carious tissue and several parameters such as bacterial invasion, degree of demineralization, and softness of dentin helped develop an understanding of the carious process. As histologic terms are less helpful when communicating with dentists in the clinical setting, and for practical purposes when trying to describe which carious tissue should be removed, the ICCC39 described the dierent physical properties associated with the dierent status of dentin as follows:Soft dentin will deform when a hard instrument is pressed onto it and can be easily scooped up (e.g., with a sharp excavator), with little force being required.Leathery dentin does not deform when an instrument is pressed onto it, but it can still be lifted without much force. ere might be little dierence between leathery and rm dentin, while leathery is a transition in the spectrum between soft and rm dentin.Firm dentin is physically resistant to hand excavation, and some pressure needs to be exerted through an instrument to lift it.Hard dentin: A pushing force needs to be used with a hard instrument to engage the dentin. Only a sharp cutting-edge instru-ment or a bur will lift it. A scratchy sound or “cri dentinaire” can be heard when a straight probe is taken across the dentin.As dental caries is a biolm disease, the ICCC suggests both prevention of new lesions and management of existing lesions should focus primarily on control or management rather than tissue removal. Noncavitated (cleansable) lesions can be managed with biolm removal (toothbrushing) and/or remineralization. Cavitated (noncleansable) dentin carious lesions cannot be managed by biolm removal, and remineralization and restorative interven-tions are indicated.47To remove carious tissue in teeth with vital pulps and without signs of irreversible pulp inammation, several strategies are available, based on the previously mentioned level of hardness of the remaining dentin.48 e decision among these strategies will be guided by the depth of the lesion and by the dentition (primary or permanent).Nonselective removal to hard dentin (complete excavation or complete caries removal) uses the same criteria for carious tissue removal both peripherally and pulpally, and only hard dentin is left. is is considered overtreatment and is no longer advocated (ICCC). 338 Part 3 The Primary Dentition Years: Three to Six Yearsa large store of potentially bioactive molecules, it has been considered that the interaction of a high pH material, such as calcium hydroxide or MTA, may cause the release of some of these molecules. is action is similar to that occurring during the demineralization of dentin during a caries attack, where the pH of the local environment is low.63When resin-modied glass ionomers are placed into a cavity preparation or on an exposed pulp, their initial pH within the rst 24 hours is approximately 4.0 to 5.5. erefore the glass ionomer demineralizes the adjacent dentin, releasing ions and potentially the sequestered bioactive materials as well. e pulpal response to glass ionomer is favorable when a layer of dentin remains between the material and the pulp.Studies of DPC with glass ionomer show that both patient tolerance and clinical success rates are lower with ionomer than calcium hydroxide. is nding suggests that the acidic environment created by the glass ionomer is more damaging to the pulp than the basic environment of calcium hydroxide or MTA.19,56Dentin-bonding agents have been recommended for use in DPC64 and IPT.65 However, there are some concerns regarding IPT (selective removal to soft dentin) with these materials.63 Nakajima and coworkers66 found a signicant loss of bond strength to human carious dentin when compared with sound dentin. is nding leads one to further question the integrity of the bond and subsequent ability to prevent bacterial invasion of a carious substrate.Contrary to previous beliefs, IPT can also be an acceptable procedure for primary teeth with reversible pulp inammation, provided that the diagnosis is based on a good history and proper clinical and radiographic examination and the tooth has been sealed with a leakage-free restoration.67e value of taking a good history complemented by a careful clinical and radiographic examination cannot be overstated when trying to reach an accurate diagnosis. However, sometimes this cannot be achieved, and the prognosis of the tooth will be aected. Fig. 23.11A and B show the treatment outcome of two mandibular rst primary molars in the same patient. e tooth treated with an MTA pulpotomy presents internal root resorption, whereas its antimere, restored conservatively with a composite over an IPT, looks normal. ese ndings were probably attributable to the preoperative status of the pulp. e radicular pulp of the pulpoto-mized tooth was probably chronically inamed at the time of treatment but could not be disclosed even by operative diagnosis.Success rates of IPT have been reported to be higher than 90% in primary teeth, and thus its use is recommended in patients whose preoperative diagnosis suggests no signs of pulp degeneration. Ricketts and colleagues68 concluded that “in deep lesions, partial caries removal is preferable to complete caries removal to reduce the risk of carious exposure.” Several articles reported the success of this technique in primary teeth.58,69–72 e overall success of IPT (selective removal to soft dentin) has been reported to be higher than the success rates of DPC or pulpotomy, the alternative pulp treatments for primary molars with deep dentinal caries.58,69–73 One can conclude that, on the basis of these biological changes and the growing evidence of the success of IPT in primary teeth, we can recommend IPT (selective removal to soft dentin) as the most appropriate treatment for symptom-free primary teeth with deep caries, provided that a proper, leakage-free restoration can be placed.A recent systematic review and meta-analysis on primary tooth vital pulp therapy74 demonstrated that the “highest level of success and quality of evidence supported IPT and the pulpotomy carious dentin is covered with a biocompatible material. is results in the deposition of tertiary dentin, increasing the distance between the remaining soft dentin and the pulp, and in the deposition of peritubular (sclerotic) dentin, which decreases dentin permeability. It is important to remove the carious tissue completely from the dentinoenamel junction and from the lateral walls of the cavity to achieve optimal interfacial seal between the tooth and the restorative material, thus preventing microleakage.As previously described, IPT (selective removal to soft dentin) is recommended in deep cavitated lesions (radiographically extending into the pulpal third or quarter of the dentin). Soft carious tissue is left over the pulp to avoid exposure and further injury, while peripheral enamel and dentin are prepared to hard dentin, to allow a tight seal and a durable restoration. Selective removal to soft dentin reduces the risk of pulp exposure signicantly when compared with nonselective removal to hard dentin or selective removal to rm dentin (see Fig. 23.9A–E). Clinical experience and a good understanding of the process of caries progression can allow for better control of the “partial removal caries (selective removal to soft dentin)” step. A large round bur (no. 6 or 8) can provide better results than spoon excavators.58 e ultimate objective of this treatment is to maintain pulp vitality59 by (1) arresting the carious process, (2) promoting dentin sclerosis (reducing perme-ability), (3) stimulating the formation of tertiary dentin, and (4) remineralizing the carious dentin.A chemomechanical approach to caries excavation known as Carisolv (Medi Team Dental, Savedalen, Sweden) has been devel-oped. A gel made of three amino acids and a low concentration of sodium hypochlorite is rubbed into the carious dentin with specially designed hand instruments. With Carisolv, sound and carious dentin are clinically separated, and only carious dentin is removed, resulting in a more conservative preparation. When a bur is used, healthy tissue is frequently removed. e main drawback to this technique is the time needed to complete the procedure, because it is a much slower process than removing caries with a bur.60Another chemomechanical product has been developed in Brazil under the commercial name of Papacarie (Fórmula & Ação, São Paulo, SP, Brazil). is product is a gel containing papain, an enzyme similar to human pepsin, that acts as a debriding agent with no harm to healthy tissue. No statistical dierence was observed in a clinical study after 6 to 18 months when papain was compared with conventional caries removal in primary teeth.61It is current knowledge that, in the appropriate metabolic state of the dentin-pulp complex, a new generation of odontoblast-like cells might dierentiate and form tubular tertiary dentin (reparative dentinogenesis).8,62 It must be emphasized that under clinical conditions, the matrix formed at the pulp-dentin interface often comprises reactionary dentin, reparative dentin, or brodentin formation. It is impossible to distinguish these processes in vivo, and the process might also be indistinguishable at both biochemical and molecular levels.Presently, the materials most commonly used in IPT (selective removal to soft dentin) are calcium hydroxide, glass ionomer, and mineral trioxide aggregate (MTA). Many historical studies have examined the interaction between tooth tissues and calcium hydroxide, and more recently with MTA. The main soluble component from MTA has been shown to be calcium hydroxide. e clinical response of the tooth to both materials is based on comparable mechanisms involving the dissolution of calcium hydroxide and release of calcium and hydroxyl ions, raising the pH of the environment well above 7.0. Because dentin contains CHAPTER 23 Pulp Therapy for the Primary Dentition 339 DPC of a carious pulp exposure in a primary tooth is not recom-mended but can be used with success on immature permanent teeth. e direct pulp cap is indicated for small mechanical or traumatic exposures when conditions for a favorable response are optimal. Even in these cases, the success rate is not particularly high in primary teeth. Failure of treatment may result in internal resorption (Fig. 23.12A and B) or acute dentoalveolar abscess. Kennedy and Kapala78 claim that the high cellular content of the primary pulp tissue may be responsible for the increased failure rate of DPC in primary teeth. ese authors believe that undif-ferentiated mesenchymal cells may dierentiate into odontoclasts, leading to internal resorption, a principal sign of failure of DPC in primary teeth.Some investigators advocate the use of dentin-bonding agents for DPC.64,79 e rationale for this is based on the belief that if an eective, permanent seal against bacterial invasion is provided, pulp healing will occur. Animal research has shown the good compatibility of mechanically exposed pulps to visible light–activated composite when bacteria are excluded.18 Araujo and associates80 reported good clinical and radiographic results in cariously exposed primary teeth 1 year after acid etching and capping with a bonding agent and restoration with a resin-based composite. Based on these reports, Kopel81 proposed a “revisitation” of the DPC technique in primary teeth. He suggested “gently wiping the dentin oor techniques of MTA and FC for the treatment of deep caries in primary teeth after 24 months. DPC showed similar success rates to IPT and MTA or FC pulpotomies, but the quality of evidence was lower.”New experimental strategies use bioactive molecules such as enamel matrix protein (Emdogain [Straumann Canada Limited, Burlington, Ontario]) or TGF-β to stimulate tertiary dentin forma-tion and decrease dentin permeability. However, these are not yet in clinical use.3Direct Pulp CappingDPC is carried out when a healthy pulp has been inadvertently exposed during an operative procedure. The tooth must be asymptomatic, and the exposure site must be pinpoint in diameter and free of oral contaminants. A calcium hydroxide medicament is placed over the exposure site to stimulate dentin formation and thus “heal” the wound and maintain the vitality of the pulp.2 e eectiveness of TGF-β and BMPs in inducing reparative dentino-genesis in pulp capping situations in vivo75–77 provides the basis for development of a possible new generation of biomaterials. Because the specicity of these growth factors to induce reparative processes is not clear, more studies are required to fully explain the kinetics of growth factor release and the sequence of growth factor–induced reparative dentinogenesis.A B• Figure 23.11 (A) Mandibular rst primary molars of the same patient 3 years after treatment of deep caries. Tooth treated with mineral trioxide aggregate pulpotomy. Internal resorption is evident. (B) Contra-lateral tooth treated conservatively with indirect pulp treatment and a composite restoration. The pulp looks normal. A B• Figure 23.12 (A) Maxillary primary central incisor treated by direct pulp capping with CaOH2 following pinpoint iatrogenic pulp exposure. (B) Extensive internal resorption was evident 6 months later.

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