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PULPOTOMY
By :Shrikant Kendre
Mds 1st year
Dept. Paedodontic and preventive dentistry
CONTENT
 Introduction
 Goal And Objective
 Definition
 Indication
 Contraindication
 Classification
 Devitalization...
INTRODUCTION
• The main objective of pulp therapy is to
maintain the integrity and health of a tooth
affected by caries, t...
GOAL AND OBJECTIVE
• RADICULAR pulp should be remain asymptomatic
without adverse clinical signs or symptoms such
as sensi...
definition-:
• PULPOTOMY CAN BE DEFINED AS THE COMPLETE
REMOVAL OF CORONAL PORTION OF THE DENTAL
PULP , FOLLOWED BY PLACEM...
INDICATION-:
 Cariously exposed primary teeth, when their retention is more
advantageous than extraction.
 Vital tooth w...
.
CONTRAINDICATION :-
• History of unprovoked toothache
• Presence of sinus or swelling
• Evidence of necrotic/irreversibly ...
CLASSIFICATION-:
• I. Vital Pulpotomy techniques
1. DEVITALIZATION: (mummification & cauterization)
 Single Sitting: 1. F...
• 2.PRESERVATION: 1.Glutaraldehyde
2.Ferric sulphate
3.REGENERATION: (inductive & reparative)
1. Bone morphogenic protein
...
A. DEVITALIZATION (SINGLE SITTING)
• FORMOCRESOL PULPOTOMY TECHNIQUE
• First advocated by SWEET(1930)
• FORMOCRESOL SOLUTI...
Mechanism Of Action:
formocresol act through aldehyde group of
formaldehyde ,forming bond with side group of
amino acids o...
Histolgic effect after application of
formocresol
• Massler and mansukhani 1959 have described the
following histological ...
Technique for Pulpotomy
of the
Primary Teeth
1. Identification/Diagnosis of offending tooth based
upon diagnostic criteria (history, symptoms,
radiographic and clinica...
4. Place Rubber Dam -Rubber Dam Placement/Utilization is
a Necessity when performing pulp therapy!
5. With a slow speed
ha...
6. With a high speed
hand piece and bur,
remove roof of pulp
chamber exposing all
canals
7. Remove all coronal
pulp with a slow speed
hand piece and a #4 or
#6 round bur. Remove
all vital tissue “ledges”
near ca...
8. After all coronal pulp
tissue has been
removed, wet 2-3
cotton pellets with
formocresol and
squeeze between
2 x 2 gauze...
9. If hemorrhage has ceased, place a thick mix of zinc oxide
and eugenol paste into the chamber (use an amalgam
carrier & ...
.
.
• Formocresol Local Toxicity
– Ranly, 1984
– Local tissue irritation
– Histologic failure—persistent chronic inflammation
...
• Formocresol Tissue Effects
– Highly toxic to cells
– Depresses fibroblastic activity and matrix
synthesis
– Blocks RNA a...
• Because of single aldehyde ring fixation of
pulp is not stable and zone of fixation
gradually progress towards apex
• It...
Why not formocresol
• Milnes A. “is formocresol obsolete? As fresh look at
the evidence concerning safety issue”
Peditr De...
Do we still need formocresol in
pediatric dentistry :Michael j.
• In randomized clinical trials with the known risk of
for...
• - So there is need of alternative material to
formocresol which gives same or more better
results as pulpotomy material.
SODIUM HYPOCHLORITE
ADVANTAGES
• Readily available
• Affordable
• Easy to handle
• Proven track record as an
antiseptic in...
sodium hypochlorite
• 3% sodium hypochlorite provided similar
treatment outcomes as compared to
formocresol
• 5% NaOCl pro...
Mechanism Of Action
• have a targeted antimicrobial action and the ability
to dissolve organic tissues
• a formation of ch...
Technique
• Very simple
• Basically same as formocresol pulpotomy
• No special armamentarium
“PLACE AND SQUEEZED OUT 5%NaO...
• NaOCL had 100% clinical success and 79%
radiographic success
(preliminary evaluation of sodium hypochlorite for pulpotom...
Sodium Hypochlorite Vs Formocresol as Pulpotomy
Medicaments in Primary Molars: Mahboobeh .
Pediatric Dentistry V 35 I No 4...
“sodium hypochlorite (NaOCI) seems to be a
suitable alternative for FC very good
antimicrobial and haemostatic agent”
DEVITALIZATION PULPOTOMY
(TWO STAGE)
• Two stage procedure involves use of paraformaldehyde
to fix the entire coronal & ra...
• Contraindication:
.Non restorable
.Necrotic
.Soon to be exfoliated
• Formula of each agent used are as follows:
– 1.GYSI...
– 2.EASLICK’S PARAFORMALDEHYDE FORMULA:
*paraformaldehyde 1 gm
*procaine base 0.03 gm
*powdered asbestos 0.05 gm
*petroleu...
First appointment:
• Isolation of the affected teeth with rubber dam
– Preparation of the cavity , excavate the caries
• O...
Second appointment
– The roof of the pulp chamber is removed and
cleaned with saline and dried with cotton pellet
– The pu...
PARTIAL PULPOTOMY
used for traumatic exposures
procedure :
inflamed pulp tissue beneath an exposure is removed to
a depth ...
Mechanism of action
• It is the ionic disassociation of calcium
hydroxide into calcium and hydroxyl ions and
their effect on bacteria and tiss...
USING MTA INSTEAD OF
FORMOCRESOL FOR PULPOTOMY
• In this new technique, the MTA paste is allowed to
cover the dry pulp stu...
PROPERTIES OF MTA (MINERAL
TRIOXIDE AGGREGATE)
• 93% clinical success rate
• Better biocompatibility
• Better sealing abil...
ACTION
• Liquefaction necrosis of the superficial pulp
• •Neutralization of toxicity in deeper layers
• •Coagulative necro...
How does MTA work??
• Process of formation of hard tissue barrier is not yet
known
• Tri-calcium oxide + tissue fluids = c...
• when MTA is placed in direct contact with human
tissues, material does the following:
• 1. Forms CH that releases calciu...
Clinical, radiographic and histological analysis of
the effects of pulp capping materials used in
pulpotomies of human pri...
ELECTROSURGICAL PULPOYOMY
– > Mack & Dean,1993
– > Non-pharmacological technique
– > Non-chemical devitalisation ,electroc...
– > after completion ,the pulp chamber is filled with
ZnOE.
– The tooth is then restored with stainless steel crown
– > Di...
LASER PULPOTOMY:
•
> Non- pharmacologic haemostatic technique
• > Jeng-fen Liu et al in 1999- studied the effect of
Nd:YAG...
PRESERVATION
• Chemicals which induce minimal insult to the tissue are used.
• They help to conserve vitality of the radic...
• Glutaraldehyde is available in 2%, 4%, 8% (2% is more
stable)
• In recent years, glutaraldehyde has been proposed as
an ...
Histological effect glutaraldehyde
pulpotomy
• Inflammation is limited to area adjacent to medicament
placed
• Fixation is...
FERRIC SULPHATE- Fie et al 1991
1. It is a non aldehyde haemostatic compound
(1)astringent;
(2) less inflammation than for...
• Ferric sulphate (15·5%)
• haemostatic agent in pulpotomy procedures. On contact
with blood, a ferric ion protein complex...
• Fei et al. reported
• for teeth treated with ferric sulphate and
formocresol. Although the overall success
rates were si...
ZINC OXIDE EUGENOL: Magnusson 1971
• ZOE was the first agent to be used for preservation
(minimal devitalization, noninduc...
REINFORCED ZINC OXIDE-EUGENOL
PULPOTOMY: E.K. Hui-Derksen
• Reinforced ZOE contains
polymethyl methacrylate,
zinc oxide,
a...
NON-VITAL PULPOTOMY
•
Ideally, a non-vital tooth should be treated by
pulpectomy or root canal filling
• However, pulpecto...
SELECTION CRITERIA
• History of spontaneous pain
• Swelling ,redness or soreness of mucosa
• Tooth mobility
• Tenderness t...
TECHNIQUE
• 1st appointment
• Necrotic pulp is removed
• pulp chamber is irrigated with saline & dried with
cotton pellet
...
• SECOND APPOINTMENT--
• Isolate the tooth
• Remove the temporary dressing & pellet containing
beechwood cresol
• if sign ...
REGENERATION:
•
An ideal pulpotomy treatment should leave the radicular pulp
vital , healthy and completely enclosed withi...
Bone morphogenic protein
use of BMP(bone morphogenic protein) which contains a
factor(osteogenic proteins) capable of auto...
BIODENTINE
• Biodentine is a new experimental tricalcium silicate
(Ca3SiO5) based inorganic non-metallic restorative cemen...
composition Biodentine
calcium silicate,
calcium carbonate,
zirconium oxide
• The main component of the powder is tricalci...
Technique
• The Biodentine Capsule is opened and tapped
gently on a hard surface to diffuse the powder.
• Five Drops of li...
Shayegan A.et al. Biodentine used as a pulp-capping
agent in primary pig teeth.
Pediatr Dent. 2012 Nov-Dec;34(7):e202-8
• ...
Nowicka A et al. Response of human dental pulp
capped with biodentine and mineral trioxide aggregate.
J Endod. 2013 Jun;39...
PLATELET RICH FIBRIN
• Platelet-Rich Fibrin (PRF) was first described by Choukroun
et al.
• obtained by removing the middl...
Characteristics of blood samples after centrifugation. A
fibrin clot in the middle of the tube (PRF) between the
red blood...
• PRF has a physiologic architecture that is favorable to
the healing, obtained due to the slow polymerization
process.
• ...
• There are other material which are recently used in
pulpotomy of primary tooth
1. Enriched collagen
2. Hard setting calc...
Hard setting calcium hydoxide
• Pure calcium hydroxide are more caustic than
Hard-setting calcium hydroxide pastes (Dycal,...
Conclusion
• Pulp therapy for primary dentition includes a variety
of treatment option depending on the vitality of
pulp. ...
REFERENCES
• AAPD Reference manual 2011/12
• Peditr Dent,2008;30:237-246
• Peditr Dent,2008;30:211-9
• Massler &Mansukhani...
THANK YOU
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Transcript of "Pulpotomy"

  1. 1. PULPOTOMY By :Shrikant Kendre Mds 1st year Dept. Paedodontic and preventive dentistry
  2. 2. CONTENT  Introduction  Goal And Objective  Definition  Indication  Contraindication  Classification  Devitalization 1. Single Sitting 2. Two Sitting  Partial Pulpotomy  Preservation  Regeneration
  3. 3. INTRODUCTION • The main objective of pulp therapy is to maintain the integrity and health of a tooth affected by caries, traumatic injury, or other causes. • There are 2 methods of treating the involved infected dental pulp for a primary tooth: pulpotomy or pulpectomy.
  4. 4. GOAL AND OBJECTIVE • RADICULAR pulp should be remain asymptomatic without adverse clinical signs or symptoms such as sensitivity pain or swelling • There should be no evidence of post –operative external root resorption • Internal root resorption should be self limiting and stable • There should be no harm to Succedaneous tooth  AAPD Reference manual 2011/12
  5. 5. definition-: • 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 (Finn,1985 )
  6. 6. INDICATION-:  Cariously exposed primary teeth, when their retention is more advantageous than extraction.  Vital tooth with healthy periodontium  Pain, if present not spontaneous nor persists after removal of the stimulus  Tooth which is restorable  Tooth with-2/3rd root length
  7. 7. .
  8. 8. CONTRAINDICATION :- • History of unprovoked toothache • Presence of sinus or swelling • Evidence of necrotic/irreversibly damaged pulp • Uncontrolled pulpal hemorrhage • Periapical or bifurcation radiolucency • Pathologic resorption of pulp • Primary root length less than 2/3
  9. 9. CLASSIFICATION-: • I. Vital Pulpotomy techniques 1. DEVITALIZATION: (mummification & cauterization)  Single Sitting: 1. Formocresol 2. Electro surgery 3. Laser 5.sodium hypochlorite 6.other  Two sitting: 1. Gysi triopaste 2. Easlick’s formaldehyde 3. Paraform devitalising paste
  10. 10. • 2.PRESERVATION: 1.Glutaraldehyde 2.Ferric sulphate 3.REGENERATION: (inductive & reparative) 1. Bone morphogenic protein 2. Hard setting calcium hydroxide 3. Freeze dried bone 4. Demineralized dentin 5. platelet rich protein 6. MTA • II. Non-Vital pulpotomy techniques(mortal pulpotomy) 1.Beechwood cresol 2.formocresol
  11. 11. A. DEVITALIZATION (SINGLE SITTING) • FORMOCRESOL PULPOTOMY TECHNIQUE • First advocated by SWEET(1930) • FORMOCRESOL SOLUTION: *19% formaldehyde *35% cresol *15% glycerine (veichle) Buckley’s solution: 1:5 conc. Of formocresol solution. • To prepare a 1:5 conc. Of this formula- • First thoroughly mix 3 part of glycerine with 1 part of distilled water • Then add 4 parts of this preparation to 1 part Buckley’s formocresol & thoroughly mix again
  12. 12. Mechanism Of Action: formocresol act through aldehyde group of formaldehyde ,forming bond with side group of amino acids of both bacteria and remaining pulp tissue Formocresol prevents tissue autolysis by bonding to protein.
  13. 13. Histolgic effect after application of formocresol • Massler and mansukhani 1959 have described the following histological zones after application formocresol- 1. Broad acidophilic zone of fixation 2. Pale-standing zone with diminished cellular activity 3. Zone of inflammatory cells
  14. 14. Technique for Pulpotomy of the Primary Teeth
  15. 15. 1. Identification/Diagnosis of offending tooth based upon diagnostic criteria (history, symptoms, radiographic and clinical evaluation) 2. Informed Consent – Explain to the parent/legal guardian the procedure. Answer any questions to his/her satisfaction. Document in the chart that you have been granted verbal consent for the pulpotomy procedure. 3. Achieve adequate anesthesia
  16. 16. 4. Place Rubber Dam -Rubber Dam Placement/Utilization is a Necessity when performing pulp therapy! 5. With a slow speed hand piece, remove caries
  17. 17. 6. With a high speed hand piece and bur, remove roof of pulp chamber exposing all canals
  18. 18. 7. Remove all coronal pulp with a slow speed hand piece and a #4 or #6 round bur. Remove all vital tissue “ledges” near canal orifices.
  19. 19. 8. After all coronal pulp tissue has been removed, wet 2-3 cotton pellets with formocresol and squeeze between 2 x 2 gauze to remove the excess. Place cotton pellets in the pulp chamber (making sure that they contact the pulp tissue in the coronal portion of the canals) for 5 minutes.
  20. 20. 9. If hemorrhage has ceased, place a thick mix of zinc oxide and eugenol paste into the chamber (use an amalgam carrier & a cotton pellet to ensure proper condensation/placement). 10. Complete the planned restoration. (i.e. Stainless Steel Crown) for long-term success.
  21. 21. .
  22. 22. .
  23. 23. • Formocresol Local Toxicity – Ranly, 1984 – Local tissue irritation – Histologic failure—persistent chronic inflammation – Immunologic risk – Succedaneous tooth damage – Effect on exfoliation (accelerate?) (Kurji, Zahra A.; Sigal, Michael J.; Andrews, Paul; Titley, Keith. Pediatric Dentistry. Mar/Apr2011, Vol. 33 Issue 2, p139-143.)
  24. 24. • Formocresol Tissue Effects – Highly toxic to cells – Depresses fibroblastic activity and matrix synthesis – Blocks RNA and protein synthesis – Chronic inflammatory response – May be a systemic concern when doing multiple treatments (i.e. OR case)
  25. 25. • Because of single aldehyde ring fixation of pulp is not stable and zone of fixation gradually progress towards apex • It is now proven that the formocresol show carcinogenic or mutagenic changes in tissue • But still it is practiced by many dentists.
  26. 26. Why not formocresol • Milnes A. “is formocresol obsolete? As fresh look at the evidence concerning safety issue” Peditr Dent,2008;30:237-246 o “…it is highly unlike that formocresol with care used, it poses a cancer risk to children who undergo one or more formocresol pulpotomy procedures.”
  27. 27. Do we still need formocresol in pediatric dentistry :Michael j. • In randomized clinical trials with the known risk of formocresol and proven alternative with equal efficacy , use of formocresol in pediatric dentistry is needless . • 10% of Formaldehyde has been shown to be distributed systemically after pulpotomy was observed in doges .
  28. 28. • - So there is need of alternative material to formocresol which gives same or more better results as pulpotomy material.
  29. 29. SODIUM HYPOCHLORITE ADVANTAGES • Readily available • Affordable • Easy to handle • Proven track record as an antiseptic in endodontics for decades DISADVANTAGES • still under research at this point
  30. 30. sodium hypochlorite • 3% sodium hypochlorite provided similar treatment outcomes as compared to formocresol • 5% NaOCl provided similar treatment outcomes as compared to 15.5% (Fe3)2(SO4)3 (Vargas K, Packham B. Pediatr Dent 2006; 28: 511–517)
  31. 31. Mechanism Of Action • have a targeted antimicrobial action and the ability to dissolve organic tissues • a formation of chloramines which interferes in cellular metabolism. • an oxidative action with irreversible enzymatic inactivation in bacteria, and a lipid and fatty acid degradation.
  32. 32. Technique • Very simple • Basically same as formocresol pulpotomy • No special armamentarium “PLACE AND SQUEEZED OUT 5%NaOCL PELLET ON PULP STUMP FOR 30 SEC.”
  33. 33. • NaOCL had 100% clinical success and 79% radiographic success (preliminary evaluation of sodium hypochlorite for pulpotomies in primary molar : Kaaren G. Vargas pediater Dent 2006:28;511-517) • Sodium hypochlorite had 95% clinical and 82% overall radiographic success (Sean F.pediatric dentistry v33/no4,jul/aug)
  34. 34. Sodium Hypochlorite Vs Formocresol as Pulpotomy Medicaments in Primary Molars: Mahboobeh . Pediatric Dentistry V 35 I No 4 Jul/Aug 13 • NaOCI (applied for 15 second) or FC (applied for one minute). Clinical and radiographic signs/symptoms were blindly recorded at zero, six. and 12 months. • At six months, 100percent clinical success was found with both NaOCI, and FC. • Radiographic success rates for NaOCI were 98 percent and 92 percent at 6- and 12-month respectively. • FC group showed 94 percent and 93 percent radiographic success rates at the same periods respectively. • There was no statistically significant difference between the groups (International Journal of Paediatric Dentistry 2013; 23:145–152)
  35. 35. “sodium hypochlorite (NaOCI) seems to be a suitable alternative for FC very good antimicrobial and haemostatic agent”
  36. 36. DEVITALIZATION PULPOTOMY (TWO STAGE) • Two stage procedure involves use of paraformaldehyde to fix the entire coronal & radicular pulp tissue. • The medicaments used in this technique have a devitalizing, mummifying and bactericidal action. • Indications: .Profuse bleeding .Difficulty in controlling bleeding .Spontaneous pain .Slight purulence discharge
  37. 37. • Contraindication: .Non restorable .Necrotic .Soon to be exfoliated • Formula of each agent used are as follows: – 1.GYSI TRIOPASTE FORMULA: *tricresol 10 ml *cresol 20 ml *glyserine 4 ml *paraformaldehyde 20 ml *zinc oxide 60 gm
  38. 38. – 2.EASLICK’S PARAFORMALDEHYDE FORMULA: *paraformaldehyde 1 gm *procaine base 0.03 gm *powdered asbestos 0.05 gm *petroleum jelly 125 gm *carimine to colour – 3.PARAFORM DEVITALIZING PASTE: *paraformaldehyde 1gm *lignocaine 0.06 gm *propylene glycol 0.05 ml *carbowax 1.30 gm *carmine to colour
  39. 39. First appointment: • Isolation of the affected teeth with rubber dam – Preparation of the cavity , excavate the caries • On excavation of deep caries pulp exposure is encountered , ensure that the exposed site is free of debris – Enlarge the cavity with round bur – Cotton pellet with paraformaldehyde is placed in the exposure site ,seal it for 1 to 2 weeks • (formaldehyde gas liberated from the paraformaldehyde permeates through the coronal & radicular pulp, fixing the pulp)
  40. 40. Second appointment – The roof of the pulp chamber is removed and cleaned with saline and dried with cotton pellet – The pulp chamber is then filled with antiseptic paste and the tooth is restored.
  41. 41. PARTIAL PULPOTOMY used for traumatic exposures procedure : inflamed pulp tissue beneath an exposure is removed to a depth of 1-3 mm to reach the deeper healthy tissue – -Indicated for a vital , traumatically exposed, young permanent tooth, especially one with an incompletely formed apex. – -Calcium hydroxide or MTA is used
  42. 42. Mechanism of action
  43. 43. • It is the ionic disassociation of calcium hydroxide into calcium and hydroxyl ions and their effect on bacteria and tissue which make their use so successful. • The mechanism of action of calcium hydroxide is directly influenced by its high pH.
  44. 44. USING MTA INSTEAD OF FORMOCRESOL FOR PULPOTOMY • In this new technique, the MTA paste is allowed to cover the dry pulp stumps (instead of formocresol). • MTA is a powder composed of -Tricalcium silicate, -Bismuth oxide, -Dicalcium silicate, -Tricalciumaluminate, -Tetracalciumaluminoferrite, -Calcium sulfate dihydrate.
  45. 45. PROPERTIES OF MTA (MINERAL TRIOXIDE AGGREGATE) • 93% clinical success rate • Better biocompatibility • Better sealing ability-prevents leakage in pulpal & Periapical tissues • Less time needed for procedure • Promotes regeneration of original pulp tissue • Dentinal bridge formation is seen
  46. 46. ACTION • Liquefaction necrosis of the superficial pulp • •Neutralization of toxicity in deeper layers • •Coagulative necrosis…Irritation of adjacent pulp • •Minor inflammation response… Hard tissue barrier
  47. 47. How does MTA work?? • Process of formation of hard tissue barrier is not yet known • Tri-calcium oxide + tissue fluids = calcium hydroxide Hard-tissue formation .
  48. 48. • when MTA is placed in direct contact with human tissues, material does the following: • 1. Forms CH that releases calcium ions for cell attachment and proliferation • 2. Creates an antibacterial environment by its alkaline pH • 3. Modulates cytokine production • 4. Encourages differentiation and migration of hard tissue- producing cells • 5. Forms Hydroxyapatite on the MTA surface and provides a biologic seal
  49. 49. Clinical, radiographic and histological analysis of the effects of pulp capping materials used in pulpotomies of human primary teeth: T. M. Oliveira el. al • compare the clinical, radiographic and histological responses of the pulp to mineral trioxide aggregate (MTA), calcium hydroxide (CH) and Portland cement (PC) when used as a pulpotomy agent in human primary teeth • Results Clinically and radiographically, the MTA and PC groups showed 100 % success rates at 6, 12 and 24 months. • MTA and PC may serve as effective materials for pulpotomies of primary teeth as compared to CH. (Eur Arch Paediatr Dent (2013) 14:65–71)
  50. 50. ELECTROSURGICAL PULPOYOMY – > Mack & Dean,1993 – > Non-pharmacological technique – > Non-chemical devitalisation ,electrocautery carbonize & heat denatures, the pulp & bacterial contamination
  51. 51. – > after completion ,the pulp chamber is filled with ZnOE. – The tooth is then restored with stainless steel crown – > Disadvantage: contaminated pulp tissue does not promote adequate current penetration . – It cannot eliminate radicular pulp inflammation
  52. 52. LASER PULPOTOMY: • > Non- pharmacologic haemostatic technique • > Jeng-fen Liu et al in 1999- studied the effect of Nd:YAG laser for pulpotomy in primary tooth-100% success with no signs or symptoms
  53. 53. PRESERVATION • Chemicals which induce minimal insult to the tissue are used. • They help to conserve vitality of the radicular pulp • Chemicals used are glutaraldehyde (2-8%)and ferric sulphate • Glutaraldehyde: (by Kopel,1979) (1) superior fixation by cross-linkage (2) diffusibility is limited (3) excellent antimicrobial agent (4) causes less necrosis of pulpal tissue “IN HIGHER CONC. FOR LONGER EXPOSURE GLUTERALDEHYDE SHOWS CYTOTOXIC & MUTAGENIC EFFECTS SAME AS FORMOCRESOL”
  54. 54. • Glutaraldehyde is available in 2%, 4%, 8% (2% is more stable) • In recent years, glutaraldehyde has been proposed as an alternative to formocresol based on: its superior fixative properties self-limiting penetration, low antigenticity low toxicity the elimination of cresol. • Fuks et al. reported a success rate of 94·3% over 6 months that decreased to 82% after 25 months, which is significantly lower than that reported for formocresol.
  55. 55. Histological effect glutaraldehyde pulpotomy • Inflammation is limited to area adjacent to medicament placed • Fixation is batter than • It’s fixative and non biological properties do not promote cell proliferation • No dentinal bridge formation • Because larger molecular size do not penetrate apex (Pediatr Dent 16:403-9, 1994)  Histological zones: Atkinson et al. 1. Zone of fixation 2. Zone of pro-inflammatory fibroblast 3. Vital pulp
  56. 56. FERRIC SULPHATE- Fie et al 1991 1. It is a non aldehyde haemostatic compound (1)astringent; (2) less inflammation than formocresol (3) 92.7% radiographic success rate. (4)100% clinical success (5)root resorption is not accelerated (6) internal resorption similar to formocresol ,no systemic or local side effects
  57. 57. • Ferric sulphate (15·5%) • haemostatic agent in pulpotomy procedures. On contact with blood, a ferric ion protein complex is formed, and the membrane of this complex seals the cut vessels, producing homeostasis. • The agglutinated protein complex forms plugs which occlude the capillary orifices, preventing blood clot formation • Fuks and her co-workers compared the pulpal responses of ferric sulphate and formocresol in baboon teeth • Outcomes for both medicaments were equal after 6 weeks, with 60% of teeth in each group presenting with mild inflammation.
  58. 58. • Fei et al. reported • for teeth treated with ferric sulphate and formocresol. Although the overall success rates were similar to those from Fuks and her co-workers , the radiographic success rates for ferric sulphate fell from 97·2% after 20 months to 92% after 48 months follow-up.
  59. 59. ZINC OXIDE EUGENOL: Magnusson 1971 • ZOE was the first agent to be used for preservation (minimal devitalization, noninductive)" and is currently used as a base material in pulpotomy. • internal resorption is associated with eugenol • When ZOE used as sub base ,eugenol directly contacts with the vital tissue and causes moderate to severe inflammatory response
  60. 60. REINFORCED ZINC OXIDE-EUGENOL PULPOTOMY: E.K. Hui-Derksen • Reinforced ZOE contains polymethyl methacrylate, zinc oxide, acetic acid, and eugenol • The radiographic, clinical, and overall success rates were approximately 95%, 97%, and 94%, respectively • The success rates indicate that the reinforced zinc oxide-eugenol pulpotomy technique may be an acceptable treatment modality for primary molars requiring vital pulp therapy (Pediatr Dent 2013:35:43-6)
  61. 61. NON-VITAL PULPOTOMY • Ideally, a non-vital tooth should be treated by pulpectomy or root canal filling • However, pulpectomy of a primary molar may sometime be impracticable due to non-negotiable root canals and also due to limited patient co- operation. • Hence, a two-stage pulpotomy technique is advocated .
  62. 62. SELECTION CRITERIA • History of spontaneous pain • Swelling ,redness or soreness of mucosa • Tooth mobility • Tenderness to percussion • Radiographic evidence of root resorption
  63. 63. TECHNIQUE • 1st appointment • Necrotic pulp is removed • pulp chamber is irrigated with saline & dried with cotton pellet • Radicular pulp is treated with beachwood cersol dipped cotton pellet • Seal the cavity with temp. Cement for 1-2 weeks
  64. 64. • SECOND APPOINTMENT-- • Isolate the tooth • Remove the temporary dressing & pellet containing beechwood cresol • if sign & symptoms persist then repeat the treatment or extract the tooth • If no symptoms pulp chamber is filled with antiseptic paste • Then it can be restored with stainless steel crown
  65. 65. REGENERATION: • An ideal pulpotomy treatment should leave the radicular pulp vital , healthy and completely enclosed within an odontoblast- lined dentin chamber. • Calcium hydroxide was the first agent used in pulpotomies that demonstrated any capacity to induce regeneration of dentin.
  66. 66. Bone morphogenic protein use of BMP(bone morphogenic protein) which contains a factor(osteogenic proteins) capable of auto induction of reparative dentin formation(stimulating induction & differentiation of mesenchymal cells with varying degrees of dentinal bridge formation) • Bone morphogenic protein (BMP) is a generic term for a family of proteins which have bone-inductive properties. • Although these studies haves suggested that reparative dentine can be induced on contact with BMP • BMPs are classified as noncollagenous proteins. • human BMPs with dentinogenic properties are becoming available through recombinant technology. • We are now entering an era of pulpotomy therapy with healing as the guiding principle.
  67. 67. BIODENTINE • Biodentine is a new experimental tricalcium silicate (Ca3SiO5) based inorganic non-metallic restorative cement • commercialized and advertised as a “bioactive dentine substitute” • The material is claimed to possess * faster setting time, * increased compressive strength, * increased density, * decreased porosity and early form of reparative dentine synthesis • Biodentine and MTA are rich in calcium compounds, which is converted to calcium hydroxide in aqueous solution. • The dissociation of calcium and hydroxyl ions increases the pH of the solution and promotes an unfavorable environment for bacterial growth
  68. 68. composition Biodentine calcium silicate, calcium carbonate, zirconium oxide • The main component of the powder is tricalcium silicate, with the addition of calcium carbonate (filler) and zirconium oxide (radiopacifier). • The liquid is a solution of calcium chloride with a water- reducing agent. • A recent study investigated Biodentine’s cytotoxicity and Genotoxicity is equal to negative control group
  69. 69. Technique • The Biodentine Capsule is opened and tapped gently on a hard surface to diffuse the powder. • Five Drops of liquid from the single‐dose dispenser will be poured into the capsule, after which it is placed in a triturater for 30 seconds. • The material is recovered with spatula and placed inside the cavity with an amalgam carrier using a cotton pellet material will be condensed without excessive pressure on pulp stumps
  70. 70. Shayegan A.et al. Biodentine used as a pulp-capping agent in primary pig teeth. Pediatr Dent. 2012 Nov-Dec;34(7):e202-8 • An animal study was done to compare the response of pulp after a pulpotomy using Biodentine,Mineral trioxide aggregate and Formocresol in primary pig teeth. • Results showed a significant difference in both Biodentine and MTA as compared to Formocresol in terms of inflammatory cell response and hard tissue formation. • It was concluded that both Biodentine and Mineral trioxide aggregate are suitable and biocompatible materials for pulp therapy in primary teeth of pigs.
  71. 71. Nowicka A et al. Response of human dental pulp capped with biodentine and mineral trioxide aggregate. J Endod. 2013 Jun;39(6):743-7. • A study was done on 28 human permanent molars to evaluate response of human dental pulp capped with Biodentine and mineral trioxide aggregate. • Results showed that majority of specimens showed complete dentinal bridge formation and an absence of inflammatory pulp response.
  72. 72. PLATELET RICH FIBRIN • Platelet-Rich Fibrin (PRF) was first described by Choukroun et al. • obtained by removing the middle layer from a centrifuged blood sample. • PRF is a matrix of autologous fibrin, in which are embedded a large quantity of platelet and leukocyte cytokines during centrifugation • a study conducted by Huang et al., who concluded that the PRF causes proliferation of human Dental Pulp Cells and increases the protein expression of Osteoprotegerin (OPG) and Alkaline Phosphatase (ALP) activity.
  73. 73. Characteristics of blood samples after centrifugation. A fibrin clot in the middle of the tube (PRF) between the red blood corpuscles at the bottom and acellular plasma at the top of the tube.
  74. 74. • PRF has a physiologic architecture that is favorable to the healing, obtained due to the slow polymerization process. • PRF with immense regenerative potential will definitely alter the surgical dentistry in the near future • Main disadvantage requiring blood sampling • the field is still largely in its infancy.
  75. 75. • There are other material which are recently used in pulpotomy of primary tooth 1. Enriched collagen 2. Hard setting calcium hydroxide 3. Freeze dried bone 4. Demineralized dentin
  76. 76. Hard setting calcium hydoxide • Pure calcium hydroxide are more caustic than Hard-setting calcium hydroxide pastes (Dycal, Life,…) but both have been shown to initiate the same type of healing
  77. 77. Conclusion • Pulp therapy for primary dentition includes a variety of treatment option depending on the vitality of pulp. Conservative treatment is performed when vital pulp remains because vitality is possible once the irritation is removed.
  78. 78. REFERENCES • AAPD Reference manual 2011/12 • Peditr Dent,2008;30:237-246 • Peditr Dent,2008;30:211-9 • Massler &Mansukhani J Dent Child 1959;26:277 • Do we still need formocresol in Pediatr Dent :Michael j.casas • Vargas K, Packham B. Pediatr Dent 2006; 28: 511–517 • Sean F. Pediat Dent v33/no4,jul/aug • Pediatr Dent 16:403-9, 1994 • Peditr Dent,1990;12:198
  79. 79. THANK YOU
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