Transcript pulpotomy

PEDIATRIC ENDODONTICS
PULPOTOMY
Presented By: Dr. Rajeev Kumar Singh
DEFINITION Finn
Pulpotomy can be defined as the complete removal of coronal portion of the
dental pulp, followed by placement of suitable dressing or medicament that
will promote healing & preserve vitality of the tooth
Pulpotomy/Pulpectomy
PULP
+
OTOMY
PULP
+
ECTOMY
to make an incision or cut into
surgical excision of a part
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Removal of inflamed & infected coronal pulp thus
preserving the vitality of the radicular pulp and
allowing it to heal
Maintain the tooth in the dental arch
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 Cariously exposed primary teeth, when their retention is more
advantageous than extraction and replacement with a space maintainer.
 clinical and radiographic signs of radicular pulp vitality
 Pain, if present not spontaneous nor persists after removal of the stimulus
 Tooth which is restorable
Tooth with at least 2/3rd root length
Haemorrhage from the amputation site is bright red & easy to control
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 root resorption exceeds more than one-third of the root length
 the tooth crown is non-restorable
 highly viscous, sluggish, or absent hemorrhage is observed at the
radicular canal orifices
 marked tenderness to percussion
 mobility with locally aggravated gingivitis associated with partial or
 total radicular pulp necrosis exists
 radiolucency exists in the furcal or periradicular areas
 Persistent toothaches and coronal pus
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Indications ??
Contra-indications ??
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Classification
Vital
Devitalization
One visit
Regeneration
Non-vital
Preservation
Two visits
According to removal of coronal tissue
Partial
Complete
Devitalization Pulpotomy
(mummification, cauterization)
One visit
Formocresol
Electro surgery
Laser
Two visits
Gysi Triopaste
Easlick’s Formaldehyde
Paraform devitalizing paste
Destroy or mummify the vital tissues
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Preservation Pulpotomy
(minimal devitalization, non-inductive)
Zinc Oxide Eugenol
Glutaraldehyde
Ferric sulfate
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Maintain maximum vital tissue without induction of reparative dentin
Regeneration Pulpotomy
(inductive, reparative)
Calcium hydroxide
Bone Morphogenic Proteins
MTA
Enriched collagen
Osteogenic protein
Freezed dried bone
Formation of dentin bridge
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Classification ??
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Formocresol
introduced in 1904 by Buckley
Buckley contended that equal parts of formalin and
tricresol would react chemically with the intermediate &
end products of pulp inflammation to form a “new,
colorless, and non-infective compound of a harmless
nature.”
Buckley’s Formocresol
Formaldehyde 19%
Tricresol
35%
Glycerin
15%
Water
31%
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Formocresol
Mechanism of action
In spite of histologic studies that showed formalin,
creosol, and paraformaldehyde to be connective tissue
irritants, it was recognized early that formocresol is an
efficient bactericide.
It was also found to have the ability to prevent tissue
autolysis by the complex chemical binding of formaldehyde
with peptide groups of side chain amino acids without
changing the basic structure of protein molecule.
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Fixation of the tissue
directly under the medicament was apparent. After a 7to 14-day application, the pulps developed three distinctive
zones: (1) a broad eosinophilic zone of fixation,
(2) a broad pale-staining zone with poor cellular
definition, and (3) a zone of inflammation diffusing
apically into normal pulp tissue. After 60 days, in a limited
number of samples, the remaining tissue was
believed to be completely fixed, appearing as a strand of
eosinophilic fibrous tissue.
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One Visit devitalization
Formocresol Pulpotomy
first approach to pulpotomy treatment of primary teeth
introduced by Sweet in 1930 as multiple-visit technique
used to mummify the tissue completely
Doyle in 1962 used a two visit procedure (Complete devitalization)
Spedding in 1965 gave 5 minutes protocol (Partial devitalization)
currently 4 minutes application time is used
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Formocresol Pulpotomy
Procedure
Anesthetize the tooth & isolation with rubber dam
Access cavity preparation done & all caries removed
The entire roof of the pulp chamber is removed using a high-speed bur
All the coronal pulp is amputated with a slow-speed bur or spoon excavator
Pulp chamber is thoroughly washed with saline to remove all debris
Hemorrhage is controlled by slightly moistened cotton pellets placed over pulp
Apply diluted formocresol to the pulp using a cotton pellet
Cavity filled with ZOE paste & permanent restoration
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Stainless steel crown placed
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Formaldehyde ??
Toxic effects ??
Procedure of formocresol pulpotomy ??
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Alternatives to formocresol
in primary teeth
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Preservation approach
ZOE Pulpotomy
 Zinc oxide-eugenol (ZOE) was the first agent to used for preservation.
 Studies showed that eugenol possesses destructive properties, and
cannot be placed directly on pulp.
 The success rate of ZOE pulpotomy was much less than formocresol
pulpotomy.
 Resultant inflammation & internal resorption were the causes of
failure.
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Preservation approach
Glutaraldehyde pulpotomy
 It was suggested by Gravenmade.
 Kopel in an initial study used 2% Glutaraldehyde and suggested that
it can be used in primary teeth pulpectomies.
Mechanism of action
The histologic picture of a Glutaraldehyde treated pulp shows a zone
of superficial fixation with very little underlying inflammation, so a
larger amount of radicular pulp tissue remained vital.
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Preservation approach
Glutaraldehyde pulpotomy
Advantages
 Superior fixation by cross
linkage with proteins
Disadvantages
 Solution is unstable
 Excellent antimicrobial
 Self limiting penetration
 Less necrosis of pulpal tissues
 Rapidly metabolized
 Less toxicity
 Neither optimum concentration
nor application time has been
established
 Lower levels of clinical success
with increasing time
 Less systemic distribution
As compared to formocresol
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Preservation approach
Ferric sulfate Pulpotomy
Ferric sulfate is a non-aldehyde chemical which has been used
commonly as an astringent.
Mechanism of action
 It is still unclear. It was proposed that Ferric sulfate might prevent
problems encountered with clot formation and thereby minimize the
chances for inflammation and internal resorption.
 Possibly the metal-protein clot at the surface of the pulp stumps acts as
a barrier to the irritative components of the subbase.
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Preservation approach
Ferric sulfate Pulpotomy
Application
 a 15.5% solution of ferric sulfate is applied to the radicular pulp stumps
for 10 to15 seconds.
 It may be applied using a cotton pellet or by allowing small droplets of
the solution to drip from a burnisher tip onto the surface of the pulp
tissue.
Success
 Both ferric sulfate and formocresol pulpotomies similarly give good
clinical and radiographic results, with high tooth survival rate.
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Ferric sulfate Pulpotomy
Preservation approach
MTA Pulpotomy
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Surely we agree that the ideal pulpotomy treatment
should leave the radicular pulp vital and healthy and
completely enclosed within an odontoblast-lined dentin
chamber. In this situation, the tissue would be isolated
from noxious restorative materials in the chamber,
thereby diminishing the chances of internal
resorption. Additionally, the odontoclasts of an
uninflamed pulp could enter into the exfoliative process
at the appropriate time and sustain it in a physiologic
manner. Implied in this scenario is the induction
of reparative dentin formation by the pulpotomy agent.
Unlike the other two categories for pulp treatment, the
rationale for the developing field of regeneration is
actually based on sound, biologic principles.
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Formulation of a One-Fifth Dilution
of Formocresol Solution
1 part Buckley’s formocresol solution is mixed with:
• 1 part distilled water and 3 parts glycerin.
A 5-minute application resulted in surface fixation of
normal tissue, whereas an application sealed in for 3
days produced calcific degeneration.
They concluded
that formocresol pulpotomy in primary pulp therapy
may be classified as either vital or nonvital, depending on the duration
of the formocresol application.
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a wide range of pulpal reactions occurred, from normal pulps to total
chronic inflammation. In most instances, however, the
pulp tissue in the apical region was vital with minimal
inflammation, which was in agreement with many
other studies. It was concluded from both studies that
the formocresol method should be regarded as only a
means to keep primary teeth with pulp exposures functioning
for a relatively short period of time.
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Correct diagnosis is essential to ensure the clinician
that inflammation is limited to the coronal pulp.208
Biopsy studies of pulp tissue removed from the opening
of root canals under pulpotomies have demonstrated
the unreliability of clinical assessments in primary
teeth.192 Radiographic examinations are therefore necessary
to confirm the need for pulpotomy therapy in
primary teeth. It is judicious to take bitewing and periradicular
radiographs so that the depth of caries may
be observed and the condition of the periradicular tissues
determined.
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One-Appointment Pulpotomy. Indications. This
method of treatment should be carried out only on
those restorable teeth in which it has been determined
that inflammation is confined to the coronal portion of
the pulp. When the coronal pulp is amputated, only
vital, healthy pulp tissue should remain in the root
canals (Figure 17-10).
Contraindications. Teeth with a history of spontaneous
pain should not be considered. If profuse
hemorrhage occurs on entering the pulp chamber, the
one-step pulpotomy is also contraindicated. Other
contraindications are pathologic root resorption, roots
that are two-thirds resorbed or internal root resorption,
interradicular bone loss, presence of a fistula, or
presence of pus in the chamber
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Two-Appointment Pulpotomy. Indications. The
two-appointment technique is indicated if there is (1)
evidence of sluggish or profuse bleeding at the amputation
site, (2) difficult-to-control bleeding, (3) slight
purulence in the chamber but none at the amputation
site, (4) thickening of the periodontal ligament, or (5)
a history of spontaneous pain without other contraindications.
The two-step pulpotomy can also be
used when shorter appointments are necessary to facilitate
patient management problems.
Miyamoto suggested
the two-appointment technique for uncooperative children to
minimize chair time, especially for the
initial operative visit
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Calcium hydroxide was the first agent used in
pulpotomies that demonstrated any capacity to induce
regeneration of dentin. 49 Even from the first, however,
it was observed that the procedure was not always
successful.
It is considered a safe drug relative to
formocresol, but, other than that, there are no strong
arguments for its use.
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• Contraindications. This technique should
not be
• done for teeth that are (1) nonrestorable,
(2) soon to be
• exfoliated, or (3) necrotic.
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The success rate of pulpotomy treatment
depends to a great extent on the operator’s
ability to determine whether the pulpal
inflammation is confined to the coronal pulp or
has possibly progressed into the root pulp as
well. Numerous studies have shown that this is
not possible by clinical means, and that the
diagnosis will be
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