DEFINITION: Pulpotomy can be defined as the complete removal of the coronal portion of the dental pulp , followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth(Finn,1959)
Cariously exposed primary teeth, when their retention is more advantageous than extraction. When inflammation is confined to the coronal portion of the pulp. Vital tooth with healthy periodontium Pain,if present not spontaneous nor persists after removal of the stimulus Tooth-restorable Tooth-2/3rd root length Hemorrhage from the amputation site is pale red & easy to control In mixed dentition stage primary tooth is preferable to a space maintainer INDICATION:
fistula or swelling,
the tooth crown is nonrestorable,
absent hemorrhage; profuse hemorrhage,
marked tenderness to percussion,
radiolucency exists in the furcal or periradicular areas,
2.electrosurgery 3.laser Two sittting: 1.gysi triopaste 2.Easlick’s formaldehyde 3.Paraform devitalising paste 2.PRESERVATION: (minimal devitalization & non-inductive)(maintains the vitality and normal histologic appearance of the entire radicular pulp.) 1.glutaraldehyde 2.Ferric sulphate 3.MTA 3.REGENERATION: (inductive & reparative) 1.bone morphogenic protein II.Non-Vital pulpotomy techniques(mortal pulpotomy) Beechwood cresol formocresol
TREATMENT OBJECTIVES: >amputate the infected coronal pulp, >neutralize any residual infectious process, >preserve the vitality of the radicular pulp. >Avoid breakdown of periradicular area >Treat remaining pulp with medicament >Avoid dystrophic pulpal changes
DEVIALIZATION-single sittingFormocresol pulpotomy technique First advocated by SWEET(1930) FORMOCRESOL SOLUTION: *19% formaldehyde *35% cresol *15% glycerine Buckley’s solution: 1:5 conc. Of formocresol solution. Mechanism of action: formocresol prevents tissue autolysis by bonding to protein. This is reversible process and is accomplished iwthout changing the basic overall structure of the protein molecules Formocresol: (1) fixative; (2) chronic inflammation; (3) possibly mutagenic or carcinogenic; (4) 83.8% success rate.
Technique for Pulptomy of the Primary Teeth 1. Profound anesthesia for tooth and tissue. 2. Isolate the tooth to be treated with a rubber dam. 3. access opening done. Excavate all caries. 4. Remove the dentin roof of the pulp chamber. 5. Remove all coronal pulp tissue with a slow-speed No. 6 or 8 round bur or sharp spoon excavator .
6. Achieve hemostasis with dry cotton pellets under pressure. 7. Apply diluted formocresol to pulp on cotton pellet for 3- 5 minutes. Pressure on pellet. 8. Prepare tooth for Stainless steel crown 9. Pulp stumps should appear dry. 10. Place a thick paste of ZOE in contact with pulp stumps. 11. Place stainless steel crown (or bonded composite)
DEVIALIZATION-two sittingformacresolpulpotomy technique ~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:
.Difficulty in controlling bleeding
.Slight purulence discharge
.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
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 1500 1.30 gm *carmine to colour
isolation of the affected teeth with rubber dam
Preparation of the cavity,excavate the caries
On excavaction of deep caries pulp exposure is encountered,ensure that the exposed site is free of debris.
Enlarge the cavity with round bur
Cotton pellet incorporated with paraformaldehyde is placed in the exposure site ,seal it for 1 to 2 weeks
(formaldehyde gas liberated from the paraformaldehyde permeates thru the coronal & radicular pulp, fixing the tisues)
Second appointment In the second appt,pulpotomy Is carried with the help of LA.
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.
Alternatives for formocresol Calcium hydroxide MTA Glutaraldehyde Ferric sulphate Lasers & electrosurgery
PARTIAL PULPOTOMY- CVEK PULPOTOMY
-Indicated for a vital,traumatically exposed, young permanent tooth, especially one with an incompletely formed apex.
-Calcium hydroxide or MTA is used
Objectives for the CaOHPulpotomy of Young Permanent Teeth:
• preserve radicular vitality, • maximize the opportunity for apexogenesis (apical development and closure), • enhance continual root dentin formation. .there should be no adverse clinical signs or symptoms of sensitivity, pain or swelling
Properties of calcium hydroxide Calcific bridge formation(91% success) Germicidal activity Vital pulp remains Clinical success to be 65% Hostological success 35% Asso with internal resorption in dec. tooth Bridging may make further endodontic treatment complicated
Clinical Technique for the CaOHPulpotomy of Young Permanent Teeth 1. Anesthetize the tooth and isolate under a rubber dam. 2. Excavate all caries and establish a cavity outline. 3. Irrigate the cavity and lightly dry with cotton pellets. 4. Remove the roof of the pulp chamber. 5. Amputate the coronal pulp with a large low-speed round bur or a high-speed diamond stone with a light touch.. 6. Control hemorrhage with a cotton pellet applied with pressure or a damp pellet of hydrogen peroxide. 7. Place a calcium hydroxide mixture over the radicular pulp stumps at the canal orifices and dry with a cotton pellet. 8. Place quick-setting ZOE cement or resin-reinforced glass ionomer cement over the calcium hydroxide to seal and fill the chamber.
Properties of MTA(mineral trioxide aggregate) 93% clinical success rate Better bocompatibility 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
Using MTA Instead of Formocresol for the 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, and calcium sulfate dihydrate.• The cement’s setting time is 3 to 4 hours.• MTA paste is obtained by mixing MTA powder with sterile saline at a 3:1 powder/saline ratio.• IRM is place over the MTA.
NON-VITAL PULPOTOMY Ideally, a non-vital tooth should b 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 pulpotomytechnqiue is advocated .
> Mack & Dean,1993
> Non-pharmacological technique
> Non-chemical devitalization,whereas mummification eliminates pulp infection & vitality with chemical cross-linking and denaturation.
> After amputation of the coronal pulp,the pulp stumps are cauterized thru this method. After completion,the pulp chamber is filled with ZnOE.the tooth is then restored with stainlesss steel crown
> Disadv: contaminated pulp tisue does not promote adequate current penetration . It cannot eliminate radicular pulp inflammation
LASER PULPOTOMY: > Non- pharmocologichemostatic technique > Jeng-fen Liu et al in 1999-effect of Nd:YAG laser for pulpotomy in primary tooth-100% success with no signs or symptoms,
PRESERVATION Chemicals which induce minimal insult to the tissue are used. They help to conserve vitality of the radicular pulp Chemials used are glutaraldehyde (2-5%)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; (5) causes less dystrophic calcification in pulp canals; (6) does not stimulate a significant immune response; (7) minimal systemic distribution Ferric sulfate astringent; forms a ferric ion-protein complex that mechanically occludes capillaries; (3) less inflammation than FC (4) 92.7% radiographic success rate. (5)100% clinical success (6)root resorption is not accelerated (7)internal resorption similar to FC,no systemic or local side effects
REGENERATION: An ideal pulpotomy treatment should leave the radicular pulp vital,healthy and completely enclosed within an odontoblast-lined dentin chamber. This involves use of BMP which contains a factor(oeteogenic proteins) capable of auto induction of reparative dentin formation(stimulating induction & differentiation of mesenchymal cells with varying degrees of dentinal bridge formation) Studies has proven that recombinant human BMP-2 are more inductive
Alternatives to Using Formocresol in Primary Teeth• Glutaraldehyde: (1) superior fixation by cross-linkage; (2) diffusibility is limited; (3) excellent antimicrobial agent; (4) causes less necrosis of pulpal tissue; (5) causes less dystrophic calcification in pulp canals; (6) does not stimulate a significant immune response; (7) minimal systemic distribution .• Ferric sulfate: (1) astringent; (2) forms a ferric ion-protein complex that mechanically occludes capillaries; (3) less inflammation than FC; (4) 92.7% success rate. • Electrosurgery and laser: less successful than ferric sulfate or dilute formocresol.