AAPD Reference Manual 2022-2023

CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES

The guidelines were formulated via teleconferences, in-person meetings, and online forum discussions with members of the WG. The WG members discussed all recommendations and issues surrounding the topic under review, and all significant topics such as recommendations were voted upon anonymously. Understanding the recommendations. These clinical practice guidelines provide recommendations for non-vital pulp therapies in primary teeth. GRADE rates the strength of a recommendation as either strong or conditional in favor of or against an intervention. The strength of a recommendation presents different implications for patients, clinicians, and policymakers. A strong recommendation in favor of the intervention implies the WG is confident that the desired benefits of the intervention outweigh any undesirable effects. A strong recom mendation against the intervention implies the WG is confi dent that the undesired effects of the intervention outweigh any potential benefits. A strong recommendation (for or against) means that, in most situations, clinicians may want to follow the WG’s suggested course of action. A conditional recommendation in favor indicates that, while there is appreciable uncertainty, the desired effects may outweigh the undesired effects of the intervention. A conditional recommendation against implies that, while there is appreciable uncertainly, the undesirable effects probably outweigh the potential benefits of the intervention. A conditional recommen- dation (for or against) means the WG recognizes that the clinician may want to follow the suggested course of action while being cognizant of the various other treatment choices, individual patient’s circumstances, preferences, and values. A recommendation statement with “ must ” or “shall ” indicates an imperative need and/or duty is an essential or indispensable item/mandatory; a recommendation with “ should ” indicates the recommended need and/or duty highly desirable, and a recommendation with “ may ” or “ could ” indicates freedom or liberty to follow a suggested alternative. 6 Table 2 shows a summary of the recommendations included in this guideline. Recommendations Question 1. In primary teeth, how do we diagnose irreversible pulpitis/pulp necrosis? Recommendation: The WG’s review did not find any direct evidence to make a recommendation on the criteria to be used by clinicians for diagnosing irreversible pulpitis/pulp necrosis in primary teeth. It is suggested that a child’s tooth with one or more clinical signs or symptoms of unprovoked toothache, sinus tract or other soft tissue pathology, gingival swelling not associated with periodontal disease, abnormal tooth mobility, or radiographically furcation or periapical radiolucency or external or internal root resorption be diagnosed as having irreversible pulpitis/pulp necrosis (Figure; see normal/reversible pulpitis and irreversible pulpitis/necrosis).

Summary of findings: The clinical signs and symptoms and radiographic findings suggestive of irreversible pulpitis/pulp necrosis in primary teeth were based on the selection criteria used by the studies included in the SR. 1 Diagnosis of irreversible pulpitis cannot be based solely on pulpal bleeding that cannot be controlled within five minutes. 7 Remarks: According to the AAPD best practices for pulp therapy for primary and immature permanent teeth, 2 a tooth planned for pulpotomy where the hemorrhage cannot be “controlled with a damp cotton pellet applied for several minutes” exhibits signs of irreversible pulpitis. There is no reference for this statement. A recent study 7 concluded that “controlling bleeding at the exposure site or canal orifices does not provide an accurate assessment of inflammation at the canal orifice and may be misleading for diagnosing vital pulp treatment in pri- mary teeth with carious pulp exposure.” Therefore, the inability to control pulpal hemorrhage after a few minutes may not solely be a reliable indicator of irreversible pulpitis. Question 2. In non-vital primary teeth, when should a clinician choose extraction over non-vital pulp therapy? Recommendation: The WG did not find any direct evidence to make a recommendation on the criteria to be used by clinicians for choosing extraction over non-vital pulp therapy in non-vital primary teeth. It is suggested that, for teeth deemed nonrestorable or when the patient has one or more exceptions to the guideline recommendations stated previously in this guideline and Figure, the treatment of choice may be extraction. Summary of findings: The AAPD’s SR 1 stated the RCT articles on pulpectomy and LSTR showed nonrestorable teeth were extracted. Teeth were not considered for pulpectomy or LSTR if they had an inadequate crown or extensive root structure resorption and were not restorable. Question 3. In non-vital primary teeth, does pulpectomy have better long-term success in teeth with or without root resorption? Recommendation: Evidence suggests that pulpectomy is a viable long-term treatment for non-vital primary teeth without root resorption compared to those with root resorption. There- fore, pulpectomy should be considered for non-vital primary teeth without preoperative root resorption. ( Conditional recom mendation, very low quality of evidence—12 months; conditional recommendation, very low quality of evidence—24 months. ) Summary of findings: Studies on pulpectomy success of 12 months or longer, irrespective of the root canal filler type or method of obturation, were evaluated in the SR 1 using a meta analysis comparing teeth with and without root resorption. Those without root resorption had statistically significant higher success (89 percent) compared to those with root resorption (47 percent). The quality of the evidence for this result was very low, according to the GRADE at 12 months, due to the very serious heterogeneity seen in the I 2 statistic and very serious indirectness due to the indirect comparison.

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