Pulp Therapy for the Young Permanent Dentition

  • Eyal NuniEmail author


Pulp injury caused by caries or trauma is still commonly found in the young permanent dentition. Young permanent teeth in which root development and apical closure have not been completed are termed immature teeth. After apical closure, these teeth are classified as mature teeth [1].


Root Canal Cone Beam Compute Tomography Calcium Hydroxide Mineral Trioxide Aggregate Pulp Tissue 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Fuks AB, Heling I, Nuni E. Pulp therapy for the young permanent dentition. In: Casamassimo PS, Fields HW, McTigue DJ, Nowak AJ, editors. Pediatric dentistry: infancy through adolescence. 5th ed. St. Louis: Saunders; 2013.Google Scholar
  2. 2.
    Law AS. Considerations for regeneration procedures. J Endod. 2013;39(3 Suppl):S44–56.CrossRefPubMedGoogle Scholar
  3. 3.
    Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta-percha. A retrospective clinical study. Endod Dent Traumatol. 1992;8(2):45–55.CrossRefPubMedGoogle Scholar
  4. 4.
    Graham L, Cooper PR, Cassidy N, Nor JE, Sloan AJ, Smith AJ. The effect of calcium hydroxide on solubilisation of bio-active dentine matrix components. Biomaterials. 2006;27(14):2865–73.CrossRefPubMedGoogle Scholar
  5. 5.
    Massagué J. The transforming growth factor-beta family. Annu Rev Cell Biol. 1990;6:597–641.CrossRefPubMedGoogle Scholar
  6. 6.
    Mass E, Zilberman U, Fuks AB. Partial pulpotomy: another treatment option for cariously exposed permanent molars. ASDC J Dent Child. 1995;62(5):342–5.PubMedGoogle Scholar
  7. 7.
    Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S. Assessment of reliability of electrical and thermal pulp testing agents. J Endod. 1986;12(7):301–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Fulling HJ, Andreasen JO. Influence of maturation status and tooth type of permanent teeth upon electrometric and thermal pulp testing. Scand J Dent Res. 1976;84(5):286–90.PubMedGoogle Scholar
  9. 9.
    Johnsen DC, Harshbarger J, Rymer HD. Quantitative assessment of neural development in human premolars. Anat Rec. 1983;205:421–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Perez R, Berkowitz R, McIlveen L, Forrester D. Dental trauma in children: a survey. Endod Dent Traumatol. 1991;7(5):212–3.CrossRefPubMedGoogle Scholar
  11. 11.
    AAE Consensus Conference Recommended Diagnostic Terminology. J Endod. 2009;35:1634.Google Scholar
  12. 12.
    AAE and AAOMR Joint Position Statement: use of cone beam computed tomography in endodontics 2015 update. Http://
  13. 13.
    American Academy of Pediatric Dentistry: Guideline on pulp therapy for primary and immature permanent teeth, Revised 2014. Pediatric dentistry. Reference Manual 2014–2015; p. 242–50.Google Scholar
  14. 14.
    Schwendicke F, Dorfer C, Paris S. Incomplete caries removal: a systematic review and meta-analysis. J Dent Res. 2013;92(4):306–14.CrossRefPubMedGoogle Scholar
  15. 15.
    Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious lesions by complete excavation or partial removal: a critical review. J Am Dent Assoc. 2008;139(6):705–12.PubMedCentralCrossRefPubMedGoogle Scholar
  16. 16.
    Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE. Operative caries management in adults and children. Cochrane Database Syst Rev. 2013;3:CD003808.Google Scholar
  17. 17.
    Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev. 2006;(3):CD003808.Google Scholar
  18. 18.
    Cvek M. Endodontic management and the use of calcium hydroxide in traumatized permanent teeth. In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. 4th ed. Oxford/Ames: Blackwell; 2007.Google Scholar
  19. 19.
    Bergenholtz G. Effect of bacterial products on inflammatory reactions in the dental pulp. Scand J Dent Res. 1977;85(2):122–9.PubMedGoogle Scholar
  20. 20.
    Bergenholtz G. Inflammatory response of the dental pulp to bacterial irritation. J Endod. 1981;7(3):100–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review-part I: chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16–27.CrossRefPubMedGoogle Scholar
  22. 22.
    Tronstad L, Andreasen JO, Hasselgren G, Kristerson L, Riis I. pH changes in dental tissues after root canal filling with calcium hydroxide. J Endod. 1981;7(1):17–21.CrossRefPubMedGoogle Scholar
  23. 23.
    Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives-permanent teeth. Pediatr Dent. 2008;30(3):220–4.PubMedGoogle Scholar
  24. 24.
    Schröder U. Effects of calcium hydroxide-containing pulp-capping agents on pulp cell migration, proliferation, and differentiation. J Dent Res. 1985;64:541–8.PubMedGoogle Scholar
  25. 25.
    Tziafas D, Smith AJ, Lesot H. Designing new treatment strategies in vital pulp therapy. J Dent. 2000;28(2):77–92.CrossRefPubMedGoogle Scholar
  26. 26.
    Tziafas D, Pantelidou O, Alvanou A, Belibasakis G, Papadimitriou S. The dentinogenic effect of mineral trioxide aggregate (MTA) in short-term capping experiments. Int Endod J. 2002;35(3):245–54.CrossRefPubMedGoogle Scholar
  27. 27.
    Boutsioukis C, Noula G, Lambrianidis T. Ex vivo study of the efficiency of two techniques for the removal of mineral trioxide aggregate used as a root canal filling material. J Endod. 2008;34(10):1239–42.CrossRefPubMedGoogle Scholar
  28. 28.
    Belobrov I, Parashos P. Treatment of tooth discoloration after the use of white mineral trioxide aggregate. J Endod. 2011;37(7):1017–20.CrossRefPubMedGoogle Scholar
  29. 29.
    Vallés M, Mercadé M, Duran-Sindreu F, Bourdelande JL, Roig M. Influence of light and oxygen on the color stability of five calcium silicate-based materials. J Endod. 2013;39(4):525–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Keskin C, Demiryurek EO, Ozyurek T. Color stabilities of calcium silicate-based materials in contact with different irrigation solutions. J Endod. 2015;41(3):409–11.CrossRefPubMedGoogle Scholar
  31. 31.
    Akcay M, Sari S. The effect of sodium hypochlorite application on the success of calcium hydroxide and mineral trioxide aggregate pulpotomies in primary teeth. Pediatr Dent. 2014;36(4):316–21.PubMedGoogle Scholar
  32. 32.
    Schröder U. Effect of an extra-pulpal blood clot on healing following experimental pulpotomy and capping with calcium hydroxide. Odontol Revy. 1973;24(3):257–68.PubMedGoogle Scholar
  33. 33.
    Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review. J Endod. 2011;37(5):581–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Mente J, Geletneky B, Ohle M, Koch MJ, Friedrich Ding PG, Wolff D, Dreyhaupt J, Martin N, Staehle HJ, Pfefferle T. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome. J Endod. 2010;36(5):806–13.CrossRefPubMedGoogle Scholar
  35. 35.
    Qudeimat MA, Barrieshi-Nusair KM, Owais AI. Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries. Eur Arch Paediatr Dent. 2007;8(2):99–104.CrossRefPubMedGoogle Scholar
  36. 36.
    Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod. 1978;4(8):232–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Cvek M, Cleaton-Jones PE, Austin JC, Andreasen JO. Pulp reaction to exposure after experimental crown fractures or grinding in adult monkeys. J Endod. 1982;8(9):391–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Granath LE, Hagman G. Experimental pulpotomy in human bicuspids with reference to cutting technique. Acta Odontol Scand. 1971;29(2):155–63.CrossRefPubMedGoogle Scholar
  39. 39.
    Tziafas D, Molyvdas I. The tissue reactions after capping of dog teeth with calcium hydroxide experimentally crammed into the pulp space. Oral Surg Oral Med Oral Pathol. 1988;65(5):604–8.CrossRefPubMedGoogle Scholar
  40. 40.
    Oginni AO, Adekoya-Sofowora CA, Kolawole KA. Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision. Dent Traumatol. 2009;25(6):620–5.CrossRefPubMedGoogle Scholar
  41. 41.
    Heide S, Kerekes K. Delayed partial pulpotomy in permanent incisors of monkeys. Int Endod J. 1987;20(2):65–74.CrossRefPubMedGoogle Scholar
  42. 42.
    Kaiser HJ. Management of wide open apex canals with calcium hydroxide. Presented at the 21st annual meeting of the American Association of Endodontists, Washington DC 17 Apr 1964.Google Scholar
  43. 43.
    Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: a review. Br Dent J. 1997;183(7):241–6.CrossRefPubMedGoogle Scholar
  44. 44.
    Rafter M. Apexification: a review. Dent Traumatol. 2005;21(1):1–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Hasselgren G, Olsson B, Cvek M. Effects of calcium hydroxide and sodium hypochlorite on the dissolution of necrotic porcine muscle tissue. J Endod. 1988;14(3):125–7.CrossRefPubMedGoogle Scholar
  46. 46.
    Kim D, Kim E. Antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: a literature review- part I. In vitro studies. Restor Dent Endod. 2014;39(4):241–52.PubMedCentralCrossRefPubMedGoogle Scholar
  47. 47.
    Kim D, Kim E. Antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: a literature review- part II. In vivo studies. Restor Dent Endod. 2015;40(2):97–103.PubMedCentralCrossRefPubMedGoogle Scholar
  48. 48.
    Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol. 2002;18(3):134–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Hatibović-Kofman S, Raimundo L, Zheng L, Chong L, Friedman M, Andreasen JO. Fracture resistance and histological findings of immature teeth treated with mineral trioxide aggregate. Dent Traumatol. 2008;24(3):272–6.CrossRefPubMedGoogle Scholar
  50. 50.
    Mohammadi Z. Sodium hypochlorite in endodontics: an update review. Int Dent J. 2008;58(6):329–41.CrossRefPubMedGoogle Scholar
  51. 51.
    van der Sluis LW, Versluis M, Wu MK, Wesselink PR. Passive ultrasonic irrigation of the root canal: a review of the literature. Int Endod J. 2007;40(6):415–26.CrossRefPubMedGoogle Scholar
  52. 52.
    Metzger Z, Solomonov M, Mass E. Calcium hydroxide retention in wide root canals with flaring apices. Dent Traumatol. 2001;17(2):86–92.CrossRefPubMedGoogle Scholar
  53. 53.
    Seghi RR, Nasrin S, Draney J, Katsube N. Root fortification. J Endod. 2013;39(3 Suppl):S57–62.CrossRefPubMedGoogle Scholar
  54. 54.
    Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol. 2002;18(4):217–21.CrossRefPubMedGoogle Scholar
  55. 55.
    Abouqal R, Rida S. Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(4):e36–42.CrossRefPubMedGoogle Scholar
  56. 56.
    Lee YL, Lee BS, Lin FH, Yun Lin A, Lan WH, Lin CP. Effects of physiological environments on the hydration behavior of mineral trioxide aggregate. Biomaterials. 2004;25(5):787–93.CrossRefPubMedGoogle Scholar
  57. 57.
    Yeung P, Liewehr FR, Moon PC. A quantitative comparison of the fill density of MTA produced by two placement techniques. J Endod. 2006;32(5):456–9.CrossRefPubMedGoogle Scholar
  58. 58.
    Trope M. Treatment of immature teeth with non-vital pulps and apical periodontitis. Dent Clin North Am. 2006;54(2):313–24.CrossRefGoogle Scholar
  59. 59.
    Patino MG, Neiders ME, Andreana S, Noble B, Cohen RE. Collagen as an implantable material in medicine and dentistry. J Oral Implantol. 2002;28(5):220–5.CrossRefPubMedGoogle Scholar
  60. 60.
    Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with apical periodontitis and sinus tract. Dent Traumatol. 2001;17(4):185–7.CrossRefPubMedGoogle Scholar
  61. 61.
    Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod. 2004;30(4):196–200.CrossRefPubMedGoogle Scholar
  62. 62.
    Kling M, Cvek M, Mejare I. Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Endod Dent Traumatol. 1986;2(3):83–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 1. Diagnosis of healing complications. Endod Dent Traumatol. 1995;11(2):59–68.CrossRefPubMedGoogle Scholar
  64. 64.
    Claus I, Laureys W, Cornelissen R, Dermaut LR. Histologic analysis of pulpal revascularization of autotransplanted immature teeth after removal of the original pulp tissue. Am J Orthod Dentofacial Orthop. 2004;125(1):93–9.CrossRefPubMedGoogle Scholar
  65. 65.
    Skoglund A, Tronstad L. Pulpal changes in replanted and autotransplanted immature teeth of dogs. J Endod. 1981;7(7):309–16.CrossRefPubMedGoogle Scholar
  66. 66.
    Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a review of current status and a call for action. J Endod. 2007;33(4):377–90.CrossRefPubMedGoogle Scholar
  67. 67.
    Nygaard-Ostby B. The role of the blood clot in endodontic therapy: an experimental histologic study. Acta Odontol Scand. 1961;19:323–53.CrossRefGoogle Scholar
  68. 68.
    Nygaard-Ostby B, Hjortdal O. Tissue formation in the root canal following pulp removal. Scand J Dent Res. 1971;79(5):333–49.PubMedGoogle Scholar
  69. 69.
    Horsted P, Nygaard-Ostby B. Tissue formation in the root canal after total pulpectomy and partial root filling. Oral Surg Oral Med Oral Pathol. 1978;46(2):275–82.CrossRefPubMedGoogle Scholar
  70. 70.
    Wang X, Thibodeau B, Trope M, Lin LM, Huang GT. Histologic characterization of regenerated tissues in canal space after the revitalization/revascularization of immature dog teeth with apical periodontitis. J Endod. 2010;36(1):56–63.CrossRefPubMedGoogle Scholar
  71. 71.
    Huang GT, Lin LM. Letter to the editor: comments on the use of the term “revascularization” to describe root regeneration. J Endod. 2008;34(5):511.CrossRefPubMedGoogle Scholar
  72. 72.
    Hargreaves KM, Giesler T, Henry M, Wang Y. Regeneration potential of the young permanent tooth: what does the future hold? J Endod. 2008;34(7 Suppl):S51–6.CrossRefPubMedGoogle Scholar
  73. 73.
    Trope M. Reply. J Endod. 2008;34:511–2.CrossRefGoogle Scholar
  74. 74.
    Huang GT. Apexification: the beginning of its end. Int Endod J. 2009;42(10):855–66.CrossRefPubMedGoogle Scholar
  75. 75.
    Wigler R, Kaufman AY, Lin S, Steinbock N, Hazan-Molina H, Torneck CD. Revascularization: a treatment for permanent teeth with necrotic pulp and incomplete root development. J Endod. 2013;39(3):319–26.CrossRefPubMedGoogle Scholar
  76. 76.
    American Association of Endodontists. Considerations for regenerative procedures. Available at: Revised 12 Apr 2015.
  77. 77.
    Kim JH, Kim Y, Shin SJ, Park JW, Jung IY. Tooth discoloration of immature permanent incisor associated with triple antibiotic therapy: a case report. J Endod. 2010;36(6):1086–91.CrossRefPubMedGoogle Scholar
  78. 78.
    Huang GT, Sonoyama W, Liu Y, Liu H, Wang S, Shi S. The hidden treasure in apical papilla: the potential role in pulp/dentin regeneration and bioroot engineering. J Endod. 2008;34(6):645–51.PubMedCentralCrossRefPubMedGoogle Scholar
  79. 79.
    Lovelace TW, Henry MA, Hargreaves KM, Diogenes A. Evaluation of the delivery of mesenchymal stem cells into the root canal space of necrotic immature teeth after clinical regenerative endodontic procedure. J Endod. 2011;37(2):133–8.CrossRefPubMedGoogle Scholar
  80. 80.
    Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, Iwaku M. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J. 1996;29(2):125–30.CrossRefPubMedGoogle Scholar
  81. 81.
    Sato I, Ando-Kurihara N, Kota K, Iwaku M, Hoshino E. Sterilization of infected root-canal dentine by topical application of a mixture of ciprofloxacin, metronidazole and minocycline in situ. Int Endod J. 1996;29(2):118–24.CrossRefPubMedGoogle Scholar
  82. 82.
    Windley W, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth with a triple antibiotic paste. J Endod. 2005;31(6):439–43.CrossRefPubMedGoogle Scholar
  83. 83.
    Chuensombat S, Khemaleelakul S, Chattipakorn S, Srisuwan T. Cytotoxic effects and antibacterial efficacy of a 3-antibiotic combination: an in vitro study. J Endod. 2013;39(6):813–9.CrossRefPubMedGoogle Scholar
  84. 84.
    Ruparel NB, Teixeira FB, Ferraz CC, Diogenes A. Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. J Endod. 2012;38(10):1372–5.CrossRefPubMedGoogle Scholar
  85. 85.
    Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature permanent tooth: case report and review of the literature. Pediatr Dent. 2007;29(1):47–50.PubMedGoogle Scholar
  86. 86.
    Reynolds K, Johnson JD, Cohenca N. Pulp revascularization of necrotic bilateral bicuspids using a modified novel technique to eliminate potential coronal discolouration: a case report. Int Endod J. 2009;42(1):84–92.CrossRefPubMedGoogle Scholar
  87. 87.
    Galler KM, D’Souza RN, Federlin M, Cavender AC, Hartgerink JD, Hecker S, Schmalz G. Dentin conditioning codetermines cell fate in regenerative endodontics. J Endod. 2011;37(11):1536–41.CrossRefPubMedGoogle Scholar
  88. 88.
    Thibodeau B, Teixeira F, Yamauchi M, Caplan DJ, Trope M. Pulp revascularization of immature dog teeth with apical periodontitis. J Endod. 2007;33(6):680–9.CrossRefPubMedGoogle Scholar
  89. 89.
    Iwaya S, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with periradicular abscess after luxation. Dent Traumatol. 2011;27(1):55–8.CrossRefPubMedGoogle Scholar
  90. 90.
    Geisler TM. Clinical considerations for regenerative endodontics procedures. Dent Clin North Am. 2012;56(3):603–26.CrossRefPubMedGoogle Scholar
  91. 91.
    Yamauchi N, Yamauchi S, Nagaoka H, Duggan D, Zhong S, Lee SM, Teixeira FB, Yamauchi M. Tissue engineering strategies for immature teeth with apical periodontitis. J Endod. 2011;37(3):390–7.CrossRefPubMedGoogle Scholar
  92. 92.
    Petrino JA, Boda KK, Shambarger S, Bowles WR, McClanahan SB. Challenges in regenerative endodontics: a case series. J Endod. 2010;36(3):536–41.CrossRefPubMedGoogle Scholar
  93. 93.
    Becerra P, Ricucci D, Loghin S, Gibbs JL, Lin LM. Histologic study of a human immature permanent premolar with chronic apical abscess after revascularization/revitalization. J Endod. 2014;40(1):133–9.CrossRefPubMedGoogle Scholar
  94. 94.
    Andreasen JO, Bakland LK. Pulp regeneration after non-infected and infected necrosis, what type of tissue do we want? A review. Dent Traumatol. 2012;28(1):13–8.CrossRefPubMedGoogle Scholar
  95. 95.
    Alobaid AS, Cortes LM, Lo J, Nguyen TT, Albert J, Abu-Melha AS, Lin LM, Gibbs JL. Radiographic and clinical outcomes of the treatment of immature permanent teeth by revascularization or apexification: a pilot retrospective cohort study. J Endod. 2014;40(8):1063–70.PubMedCentralCrossRefPubMedGoogle Scholar
  96. 96.
    Garcia-Godoy F, Murray PE. Recommendations for using regenerative endodontic procedures in permanent immature traumatized teeth. Dent Traumatol. 2012;28(1):33–41.CrossRefPubMedGoogle Scholar
  97. 97.
    Slutzky-Goldberg I, Heling I. Revascularization? Only as the last resort! Refuat Hapeh Vehashinayim. 2013;30(3):30–5, 62.Google Scholar
  98. 98.
    Estrela C, Rabelo LE, de Souza JB, Alencar AH, Estrela CR, Sousa Neto MD, Pécora JD. Frequency of root canal isthmi in human permanent teeth determined by cone-beam computed tomography. J Endod. 2015;41(9):1535–9.CrossRefPubMedGoogle Scholar

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© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of EndodonticsHadassah School of Dental Medicine, Hebrew UniversityJerusalemIsrael

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