From Liner to Pulpectomy: Pulpal Therapy Options for Primary Teeth

Pulpotomies have changed dramatically in the last 10 years in terms of what materials we're using. Years ago, we were using form-cresol and ferric sulfate, and those are just not recommended anymore. Welcome to the Phil Klein Dental Podcast. When faced with a compromised primary tooth, we have several options to achieve our goal of keeping the tooth healthy and functional until natural exfoliation, from protective liners and indirect pulp caps that help shield the pulp from further damage, to direct pulp caps aimed at maintaining vitality. to pulpotomies and pulpectomies when deeper intervention is necessary. Each approach plays a key role in managing pulpal health. So how do we determine the best course of action for these primary teeth? What materials and techniques yield the most predictable outcomes? And what kind of restoration will give us the highest success rate for our young patients? To tell us all about it and why it's so important to preserve these primary teeth is our guest, Dr. Carla Cohn. Dr. Cohn is a general dentist who owns her own practice in Winnipeg, Canada. Her practice is devoted solely to dentistry for children. With extensive teaching experience and numerous publications, she is recognized internationally for her contributions to continuing dental education. She's a regular contributor to VivaLearning.com. Dr. Cohn, it's a pleasure to have you on the show. And it's a pleasure to be here. Thank you for having me. Yeah, you've done some really good stuff for us in the past on Viva Learning, and your input is really important because, you know, a lot of our listeners don't have a full grasp of how to treat kiddos. They're treating kids here and there, but your practice is pretty much dedicated to treating children, is it not? It is. It's entirely dedicated to treating children for the last, I don't want to tell you how long, but a long time. Yeah. So your insight is very valuable and obviously it comes with experience. So to begin this episode, Dr. Cohn, let me ask you this. Why is pulpal therapy in primary teeth so crucial for long-term oral health? Great question. And a lot of people don't see the value in primary dentition and they call them baby teeth or milk teeth or transitional teeth. And I suppose to some degree, they're a little bit of all of that, but they're so much more important. They're kids' teeth and they're with our kids for a very long time. From the time that they erupt, first tooth erupts at age of six months or so. And last one doesn't exfoliate till that child is about 11 or 12. So they're essential for that. time of growth and that time of learning so that our kids can function so that they can speak properly so we can have space maintained for the permanent tooth eruption. And when we have pulpal disease, we need to treat it timely and appropriately so that these teeth can fulfill that role until they're ready to naturally exfoliate. And if we neglect pulpal therapy, then we have kids that have pain and infection, premature tooth loss, and that contributes to all sorts of problems, crooked teeth, trouble speaking, trouble concentrating because they've got pain, long-term dental issues. So we have a very important... role when we are taking care of our kids' teeth and not to think that they're insignificant and they're just going to be transitional. So with that introduction, and I totally agree, Dr. Cohn, the importance of preserving the primary tooth, we have several therapeutic procedures in our toolkit that we could use to preserve the pulp. And it starts off with a very benign procedure, very unaggressive, fairly routine procedure, and that's placing a protective liner. And then as we move down the line, it gets more aggressive from indirect pulp cap to direct pulp cap, pulpotomy, pulpectomy, and of course, there's extraction. So let's begin by talking about the first option, which is a protective liner. Tell us about that. So if we've got a deep lesion and our decay is removed, we've got all of the infected dentin out and only affected dentin left behind, then we have a deep lesion. We need to protect the pulp. Thermal protection, some of the materials that we use for restorative, we're hitting a light to it. If you've got a light that's going to heat things up, then we've got to be careful that we're not heating up the pulp as well and have fried pulp. That's not a good thing. We don't want to have a necrotic tube. So in order to protect that pulpal tissue, we have to put a liner on it. We want to have a liner that's going to give us some advantages, not just the thermal protection. So use something that's got a calcium silicate in it that's going to give back to the tooth, that's going to help to repair as well. Because if we're putting some of our old retired materials, let's call it, on there, what we're going to end up happening is not... not have anything except for the thermal protection. And then over time, if we're using the really old materials, they just dissolve and turn to mush. So we don't want that. We want to have a good solid base to our restoration. When we're talking about primary teeth, when we do have caries that gets very deep, we're looking at all sorts of factors for that particular child. But one of them is longevity of the restoration in that child's mouth. So what is it that we're going to do? to do, what is going to be best for that child so that we've got something that's very definitive. We don't want to have to go back in a second time. Right. So the protective liner is kind of the first step, the first line of defense. Let's talk about the indirect pulp cap. And that, of course, as we know, and many dentists are listening to this, there's some decay remaining. Right. Our goal is to arrest the decay, seal the tooth up so it's literally sitting in a sarcophagus of material where it can't really get any worse. It's not going to continue to proceed in a negative direction where it starts dissolving the dentin and so forth. So what kind of procedure does that entail, an indirect pulp cap? So if we're doing an indirect pulp cap, and we've got materials and different ways to do indirect pulp caps, more than just putting a material onto that tooth and that affected dentin. And lots of evidence out there for selective caries removal, by the way. This is something that I was never taught in school. When I graduated and for several years after that, many years after that, you needed to remove everything and have a completely clean, solid floor. Now the evidence is telling us otherwise. We can leave behind some affected dent and we can do some selective caries removal and still have success. So if we're leaving behind some caries. one of the things that we can do that's become very mainstream now is to put silver fluoride on. And that's a form of an indirect pulp therapy as well. So we're arresting the caries, we're putting the silver fluoride on, and then we can build the restoration after on top of that silver fluoride, all kinds of things that we should and shouldn't do beyond the scope of our little short time together. But the other thing for an indirect pulp therapy that we use is... something like, as I said before, a calcium silicate material. And we have these resin-modified calcium silicate materials that are very easy to use that we can use for an indirect pulp therapy that is going to, again, help to heal the tooth. That's what the calcium silicate does. When we have it in the form of a resin-modified calcium silicate, we can syringe it out, light cure it, and carry on with the procedure. We don't have to have any wait time for it to set. You've got the resin in it. the light to it, and then you carry on with your procedure. And if you're looking at the most recent literature that's out there, there was a review that was done in 2024, early 2024, and it was published in the Pediatric dental journal. It's from Dr. Cohn and that group. And the results, to cut to the chase and give you the punchline of that whole study or that whole article, is that our indirect pulp therapy is the most successful type of vital pulp therapy that we can do for our kids. It decreases the cost, it decreases the time in the chair, and it is an increased success rate. So we need to... try to make a better effort as practitioners to not invade the pulp and do these indirect pulp therapies. Yeah. So yeah, no question about it. Indirect pulp cap is way more successful than a direct pulp cap for obvious reasons. But let's move. And by the way, when you say silver fluoride, you're talking about silver diamine fluoride. Right. Yes. I hear that said both ways. So I assume. Yeah. Let's talk about the direct pulp cap. Now, when I was an endodontist. If we experienced a carious exposure, we did not go with a direct pulp cap. We immediately knew that the tooth would need root canal. Now that was on a permanent tooth. Now we're talking about primary teeth. So in this case, it's different. Tell us about a direct pulp cap and assuming that it's a non-carious exposure, which means whether it's trauma or the dentist was going down deep, really focused on cleaning everything out. and maybe overdid it a little bit, and then there was a little pinpoint exposure. And we're also assuming that bleeding did occur, for instance, but it was maintained or suppressed within a minute with some pressure from a cotton pellet. So tell us about the direct pulp cap. So in a primary tooth, the direct pulp cap still doesn't have the evidence behind it, although it is changing. So we've always been told or led to believe or from what evidence we had of the materials that we had to do it with, that a direct pulp cap on a primary tooth just go and do the pulpotomy. And that's still what's in our guidelines. As our materials change and they get better, and by better, I mean that they're more reparative and they're more. able to seal, then I think that that's going to change. So if I have a pinpoint exposure, if it's from trauma, or if it's a mechanical exposure, and the tooth is not far from exfoliation, or I have a child who's potentially, you know, losing their ability to cooperate for the appointment, then yeah, let's go ahead and we'll do that. But your material of choice is really important. So just like the indirect pulp therapy, where we want a calcium silicate, We want a calcium silicate for our direct pulp. therapy as well. And when we look at the evidence that's out there, the literature that's out there for the direct pulp therapy, when it's recommended, it's recommended with an MTA or MTA-like material. So when we're doing our direct pulp cap or our indirect pulp cap, the Theracals are really great materials. So Theracal LC is a light cure material. That's from Bisco. If you're in the States, if you're in Canada, that's distributed by Curion. And then there's Thera. Therabase. So Therabase is a similar product, but it's a dual cure and it's got better physical properties than the Theracal LC. So I can put it in thicker increments and still be confident that I've got the strength as opposed to the Theracal LC that I'd only want to have in a thinner layer. So let's talk about pulpotomy next. So that's the next step as far as how... aggressive we are with treating this or handling therapeutically the pulpal problem of a primary tooth. So a pulpotomy is indicated on a vital tooth that does have a carious exposure in contrast to the direct pulp cap we just described, which does not have a carious exposure. So the idea here is to remove the coronal pulp, seal and protect the radicular pulp tissue, and then allow the tooth to function asymptomatically until exfoliation. So tell us about the pulpotomy. And where are we now in 2025? So palpotomies have changed dramatically in the last 10 years in terms of what materials we're using. Years ago, we were using formicresol and ferric sulfate. And those are just not recommended anymore. Highly recommended against formicresol. And ferric sulfate has its problems for our palpotomies. So in this review that I was talking about from 2024, when a pulpotomy is indicated, it's indicated with an MTA, MTA-like material. And that's going to increase our success. So we're going to do our pulpotomies with... TheraCal PT or other MTA-like materials. So TheraCal PT is another Bisco product specifically for pulpotomies. It's a dual cure. The chemistry is designed specifically for pulpal therapy. And another more recent article in 2024 came out mid-year or so talking about the success rates of TheraCal PT and very, very high success rate. with the TheraCal PT. So very promising material. It's easy to use as well. Dual barrel syringe. So dual cure, light cure and a self-cure component to it. You syringe it into the pulpal chamber, hit the light to it and carry on with your procedure of your restoration, which happens obviously right after that same appointment. For the direct pulp cap where you have an exposure and the pulpotomy, obviously you're going down to the orifices of the root. After you place those materials on that you discussed, how do you typically restore the tooth and what do you tell the patient's parent or guardian? Yeah. So when we're restoring the tooth after pulpal therapy, our highest success rate is going to be with full coverage. So in the world of pediatric dentistry, that means stainless steel crown or a prefabricated aesthetic crown, which can be zirconia. It can be a resin material now. And that was because what happened was it would seal out the tooth and we wouldn't have the micro leakage. We would have failed pulpit. pulpotomies frequently because people are putting great big composite resins because that was their comfort zone that's what they knew that's what they learned and then the composite resin would would leak and then we'd have a failed pulpotomy so by virtue of doing full coverage and nothing more you increased your success rate by about 20 percent but in the last uh journal from the Pediatric Dentistry Journal, the one that's put out by AAPD, there was an article talking about restorations and micro leakage and the restorative material Activa from PulpDent, so Activa Bioactive, now they have a bulk fill, showed really promising results in the fact that we could now restore these teeth with specifically that material and expect virtually no micro leakage so this helps us as as dentists and people like as you said at the outset of this there's lots of general dentists that are don't see a lot of kids so they don't they're not comfortable doing a stainless steel ground they're not comfortable doing a pulpotomy our materials are evolving so much so that we we now have the ability to do things with them to increase our success within our comfort zone for that person that doesn't know how to do these materials make it easier. If you don't want to do a stainless steel crown, you do the Activa as a restorative intracoronally. If you're going with the stainless steel crown, not easy for me to say. steel crown what do you cement it in with what do you what's underneath that crown that actually adheres to the to the tooth structure Stainless steel crowns will cement with a resin modified glass ionomer cement. So, you know, you want to talk about companies and manufacturers. The ones that I use are a Fuji SEM from GCA, a Reliax from 3M, which is now called Solventum. And then there's also a Riva from SDI that's also a resin modified glass ionomer cement. And the way that they've got them now is like so much better than what we used to have. We used to mix up powder and liquid and it would stick. to everything. And now these materials are all syringeable. It's dual barrels. You syringe them out, mix it up, and the stainless steel crown. The reason we use those glass ionomers is because they're moisture tolerant. Every time we do a stainless steel crown, we have moisture because we're subgingival. There's hemorrhage. It's kids. Yeah, absolutely. So let's talk about pulpectomy. And that's the last of the five procedures that we're talking about. That's the most aggressive. Typically, you want to stay away from a pulpectomy if you can, but when you're planning a pulpotomy and you find out that the tooth is necrotic or there's excessive bleeding and separation that you can't control with a cotton pledget for a minute goes by and this thing's still oozing and bleeding, you certainly know that a pulpotomy is not going to be the answer here. So you move to a pulpectomy. So tell us about the primary tooth that needs a pulpectomy. primary teeth that need palpectomy. And this is not a common procedure that we do in North America. It's much more common overseas and in Asia and in Europe, we see all kinds of really beautiful, like it's full out endo on primary teeth, but it's a very technique sensitive procedure. And if you're not doing a lot of them and you're not equipped to do it, they have a very high. a failure rate. But every now and then we'll get that tooth that we just, we just need to save, you know, it's an anterior tooth, for example, and the parent just, just doesn't want to have it extracted. So pulpectomies are completely different materials. What we're going to fill our root canal with, that's going to be with something like a dipex or a vitpex, you know, something that's going to resorb. Yeah. As the tooth starts to exfoliate. But, you know, typically when I have a tooth that is, you know, I get in there and it's necrotic or it's hyperemic and the pulpotomy is not going to do it. My next line of action is usually an extraction. that tooth. You can also look at lesion sterilization, tissue repair, something like that. But pulpectomies are not a frequent thing that's done in North America. And maybe that'll change. Maybe that'll change in time as things do. So in that case where the dentist wants to proceed with doing a pulpectomy, as you mentioned, it's not a common procedure here, but let's say they... He or she wants to be heroic and go ahead with it Can they use calcium hydroxide and mix up a paste a very dense paste and pack it down the canal? No, we're going to fill it with that dipex or that vitpex. That's going to give us our best success. So that's a combination. It's got some iota form in it and it'll resorb. And the way that the material is extruded is the tip of that syringe is very thin so that we can get it down as far as possible. And then we just extrude and kind of backfill. And you got to know too, like we're guessing on the length of that. I mean, we're making an educated assumption on the length of that. canal, right? We can't tell. We have our radiograph, if we're lucky, the radiograph is going to tell us how far we need to go. And that's one of the reasons too, that it makes it so difficult to have success with pulpectomies. So what's the frequency of follow-up on some of these procedures? So if you do a pulpotomy on a kid who's, let's say he's four years old, right? And it's a lateral incisor, they come in around. nine months so he's four years old he's got three to four years left before the permanent lateral incisor comes in and you've done a pulpotomy so you have four years you want to keep that too does that sound is that correct That's a lot of math you're making me do in my head here. But okay. Yeah, I gotcha. I'm with you. Well, I mean, if a kid's four years old, and he's expecting his permanent laterals between seven and eight, then three to four years, you need to keep that tooth. So if you do a popotomy when he's four, now you've got three or four years where he's doing everything, eating candy, doing everything every kid does. What are you looking at on the recare visits? Are you scheduling that patient specifically to keep an eye on that tooth? Tell me about how you manage that to make sure that it's going in the right direction. Yeah. So, I mean, if there's any concern, then there's a more frequent recall. But if the procedure went well and we're confident that it was successful, that child's going to be on a six-month recall like everybody else. Obviously, we advise parents to watch out for swelling, pain, anything like that. And when they come in, we're checking soft tissues. But radiographic frequency is going to depend on everything else that's going on in there. is this kid a high-risk kid? Are we going to be seeing them more frequently because of other things? But just because we've got a palpectomy in there, or a palpotomy, pardon me, doesn't mean that we need to see that child any more frequently. Unless we're concerned about the actual procedure itself and that success on that particular kid. Now, you've worked with kids for a long time. How reliable is what we call as a dental history or getting their symptoms from them as a patient? Because that's very important in making these decisions on which way to go. The five therapies we just talked about, if the patient drinks cold and for only a few seconds it hurts and then it goes away, okay, that sounds like a reversible pulpitis. When someone drinks cold, hot or cold and it stays there lingering for a minute or two or it's even brought on without having to drink hot or cold and it's just kind of spontaneous. They're laying down and all of a sudden this thing is starting to go off. What do you get from a child three to four years old? Yeah, not much. Typically, kids at that age are pretty poor historians. We talk to the kids and we tell them, point where it hurts and that sort of thing, very visual. But we don't have great history from kids. And so we rely on the parents a lot at that age for history. And the other thing about that, too, is kids don't always know what feels normal and what doesn't. feel normal you got a kid that's coming into you and they've got early childhood caries and they've had decay in their mouth from the time these teeth have erupted that's normal to them and so giving a history on what's painful unless it's like acutely spontaneously painful sometimes you don't get a good history and a lot of times you're relying only on the parent and just because a child may have palpable involvement with that tooth You're not always going to have that same pain if it's draining. If we've got a pustule and we've got actively draining, it's not as uncomfortable as you would think that it should be. But it's funny that you brought that up because as I'm preparing, we're going to do a webinar together with Viva. And that's one of the things that I've got in there as critical is history and just how unreliable history can be. a two to three year old, you know, even an older child than that. Right. Now you do use pulp testing. Now in permanent teeth, they're pretty accurate. You can do a lot of stuff with pulp testing. How does that play out with kids that are three or four? years old. It doesn't, you know, I don't want to elicit pain on that child. And so, I mean, you can go in and you can do some cold testing, but I'm going to use my other methods of diagnosis rather than eliciting pain on a two to three year old, you know, visual soft tissue, radiographic history. If I can, mobility of the tooth is one color of the tooth. You know, it's all giving us clues. to be, you know, it's almost like a bit of a detective game. So we talked about various procedures that we can perform to help preserve the pulp and keep it healthy until exfoliation. In the case of a direct pulp cap, that's a little bit riskier than an indirect pulp cap, as you explained. How do you talk to the patient about that? How do you talk to the patient's parents, I should say, about that? And how do you prepare them for the event that the patient may need to come back to have a pulpotomy? which is the next step in order to preserve that primary tooth. So, and a direct pulp cap, we would say with caution. This is with caution that we're placing this and we may need to go back. And that's a conversation that is fairly common in different ways with our parent when we're seeing our kids. We'll go in and we're planning to do a filling. The conversation with the parent is this may get to be too broad and we're going to need to do a crown. We talk about a crown and it's always this may be that we need to do pulpal therapy. Do pulpal therapy. This may be that we need to do an extraction. So we have all of these conversations ahead of time, or we should be having them all ahead of time so that that parent is advised of what may happen. So all of these possible eventualities, because nothing that we do is 100%. And when you have a kid in your chair and you're working, you're trying to work. quickly, efficiently. The last thing that you want to do is have to stop and have a conversation of, oh, this happened. It's not a good situation. As we wrap up this podcast, Dr. Cohn, I think it's important to reemphasize not only the techniques are critical, that we make the right diagnosis so we can do the right procedure on the patient. to preserve the tooth until exfoliation, but also use the right materials and stay attuned to the research and development by the companies that are doing the work to bring us those materials. And I know you're a big fan of VSCO products. They work. Yeah, and they have a great R&D team that specializes in this. I mean, this is what they, their CEO is a chemist, PhD chemist, who from the ground up started the company. It's a really success story. It is. As these products get more advanced, what do you see happening down the road in the future for pulp therapy for primary teeth? What do you see happening ultimately in the next two to five years? In that crystal ball, in two to five years, I think we're probably still going to be doing something very similar. But I think that as the trend is going with our success, we're going to be moving more and more to minimally invasive dentistry, leaving more caries behind and sealing it off so that we can go in less and less to that tooth. And anytime we can minimize the contact with that tooth, I think that that's a benefit to everybody. So we'll see what happens. I mean, I certainly never imagined that we'd be doing what we're doing now, you know, 10 years ago or even five years ago with the successes that we're having and really pleased to see the evidence more and more coming at us that these are very successful materials and giving us the ability to make our lives and our patients' lives easier. Yeah, and we haven't really talked about the self-esteem of the kid. I mean, you think like, okay, the kid doesn't have to go to a board meeting. meeting or he's not on a TV commercial, although he might be or he or she might be. But in general, it's just a kid. They all play together. Nobody cares. But when a kid three or four years old loses their tooth and it's visible, they have social pressure too. They do. They do. You know, the playground pressure is huge. And this is when the kids are developing their self-esteem, right? And their social connections. So it is important. Kids care and whether they can vocalize that or not is another thing, but it is important. The aesthetics of a kid's mouth is really important for their growth. So in closing, Dr. Cohn, some of our audience may want to reach out to you for more information. What's the best way for them to get a hold of you? The best way is to go to my website, litsmileacademy.com. And you can reach out to me at the email as well, info at litsmileacademy.com. And you have some courses that you're giving. Tell us quickly about those and they'll be able to get more information on your website, I assume. I do. Everything's listed on the website. June 7, I'm going to do a hands-on workshop out in Vancouver. It's going to be a full day. We're going to do everything from minimally invasive to full coverage pulpotomies. And that's a fantastic opportunity to work with all of the materials and do all of the procedures that you can do for pediatric dentistry. And then the other one is a really exciting one. I've got a travel CE coming up in Mexico. We're going to go to Excellence Playa Mujeres in Mexico, November 15 to 22. We're going to do four. didactic courses. We're going to do some pedo. I've got a colleague, Dr. Rodrigo Sanchez-Cuña is going to talk about endodontics. And I've got a chiropractor who also happens to be my husband and he's going to do ergonomics. So that's going to be a fantastic one. Both of those are on litsmileacademy.com. Yeah. And that's why you're sitting up so straight all the time because your husband is a chiropractor. Yeah. I knew there was something behind it. All right. Well, listen, great stuff. Thank you so much, Dr. Cohn. We'll see you soon. Thank you. My pleasure to be here. Thank you for having me.