PULPOTOMY- Dr. Amrutha Joy

1. pulpotomy
DR. AMRUTHA JOY
READER
DEPT.OF PEDIATRIC DENTISTRY
ROYAL DENTAL COLLEGE

2. INTRODUCTION
 The aim of pulpotomy is to
preserve the radicular pulp,
avoid pain and swelling,
retain the tooth,
preserve arch integrity.

3. DEFINITION- PULPOTOMY
 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 the vitality of the tooth. Finn,1959
 A complete or traditional pulpotomy involves complete surgical removal of the
coronal vital pulp tissue followed by placement of a biologically acceptable
material in the pulp chamber and restoration of the tooth. AAPD

4. Objective
 To remove inflamed coronal portion of pulp
 Allow the pulp tissue in the root canal to remain vital
 Maintain tooth in dental arch

5. Rationale
 Radicular pulp is healthy & capable of healing after
surgical amputation of infected pulp
 Preserve vitality of radicular pulp
 Maintain tooth in physiologic condition

6. Indications
 Tooth free of irreversible pulpitis, in spite of having a large carious lesion
 Neither spontaneous nor persistent pain.
 Restorable tooth
 Atleast 2/3rd of root length
 No internal resorption, interradicular bone loss, abscess or fistula
 Hemorrhage from amputation site pale red & easy to control

7. Contraindications
 Persistent/spontaneous tooth ache
 Root resorption→ < 1/3rd
 Non-restorable
 Highly viscous, sluggish , uncontrollable hemorrhage from canal orifice
 Medical → heart disease, immuno-compromised patients
 Presence of swelling, fistula, external or internal resorption
 Pathologic mobility
 Calcified canals

8. Classification
Based on treatment objectives: (Don M. Ranly 1994)
VITAL PULPOTOMY
• Devitalization Pulpotomy (Mummification, Cauterization)
• Preservation Pulpotomy (Minimal devitalization, Non – inductive)
• Regeneration Pulpotomy (Inductive, Reparative)
NON –VITAL PULPOTOMY
• Beechwood cresol
• Formocresol

9. According to the extent of amputation :
• Partial pulpotomy ( Cvek’s pulpotomy)
• Complete pulpotomy

10. Ideal Pulpotomy Material
 Bactericidal
 Harmless to pulp & surrounding tissue
 Promote healing of radicular pulp
 Preserve the radicular pulp without any clinical or radiographic
symptoms
 Not interfere with physiologic root resorption

11. Partial Pulpotomy
(Cvek’s Pulpotomy)
 It is the removal of only the outer layer of damaged and
hyperaemic tissue in exposed pulps.
 It is considered to be a procedure staged between pulp capping
and complete pulpotomy.
 Widely used in the permanent dentition.

12. Technique
 Local anaesthesia and rubber dam placement.
 A no. 330 tungsten bur is used to amputate the pulp close to the exposure site to a depth of
1-3 mm.
 Continuous rinsing of the amputated pulp with saline will assist in achieving hemostasis
without blood clot formation within 4 minutes
 A dressing of calcium hydroxide paste should be placed followed by base/liner of glass
ionomer.

13.  The tooth is subsequently prepared for a full coverage restoration.
 Scheduled follow-ups should be made after 1 month and then every 6 months.
 A dentin bridge will begin to form, separating the exposure site from the rest of the pulp.
 The bridge may be evidenced radiographically after 6 to 8 weeks in a periapical view.

15. Devitalizing Pulpotomy
 Mummification/ Cauterization
 Single / Two visit
 Intended to mummify the vital tissue
 Single Sitting: a) Formocresol
b) Electrosurgery
c) Laser
 Two Sitting: a) Gysi Triopaste
b) Easlick’s Formaldehyde
c) Paraform Devitalizing paste

16. Formocresol pulpotomy
 Advocated by Sweet (1932)
 Medicament of choice for primary teeth
 Buckley’s Formocresol
Composition
Cresol- 35%
Glycerine- 15%
Formaldehyde- 19%
Water- 31%

17.  Currently 1/5th concentration of Buckley’s formula is used
Mechanism of Action
 Inhibits autolytic changes and bacterial growth
 Zone of fixation is bacteria free and inert, resistant to autolysis and
acts as a deterrent to further microbial infiltration

18. PROCEDURE
 Anesthetize & Isolate
 Remove all caries before entering pulp chamber

19.  Remove dentinal roof using round bur
 Enlarge the exposed area and deroof the pulp chamber
 Remove any ledges or overhanging enamel
 Scoop out coronal pulp & pulp remnants using sharp spoon excavator

20.  Clean the pulp chamber with saline & remove all debris
 Hemostasis →cotton pellet
 Apply 1/5th conc of Buckley’s Formocresol for 5 min.
 Remove cotton pellet & check for fixation
 Brownish discoloration of pellet & pulp stump indicates fixation

21.  Place ZOE cement in pulp chamber
 Recall after a week & permanent restoration
 Stainless steel crown

24. Histologic evaluation
 In 7-14 days, 3 distinct zones are noted :
1. Broad acidophilic zone of fixation
2. Broad pale-staining zone of atrophy with fewer cells and fibers
3. Broad zone of inflammatory cells, extending apically
 A progressive apical movement of these zones was described with only the acidophilic
zone left at the end of 1 year.

25. DISADVANTAGES
 Caustic to tissues
 Toxicity
 Formocresol & formaldehyde have shown to be
cytotoxic, mutagenic & carcinogenic in animal
experiments

26. Laser Pulpotomy
 Non-pharmacological technique
 laser used (Nd.YAG, Argon, CO2)
 After complete extirpation of coronal pulp expose to laser at 20 Hz
 Laser irradiation creates a superficial zone of coagulation necrosis that remains
compatible with the underlying tissue
 Pulp retains its vitality and capability of normal healing
 Restoration

27. Advantages
 Hemostasis
 Preservation of vital tissues near the tooth apex
 Absence of vibration and odor may lead to satisfaction of children and their
parents

28. Electrosurgical pulpotomy
 Mark, first US dentist to perform electrosurgical pulpotomy in 1993, with 99%
success rate
Procedure
 Till Hemostasis, similar to conventional
 Dental electrode used to deliver the electrical arc

29.  Electrode is placed 1-2 mm above pulpal stump
 Electrical arc allowed to bridge the gap to pulp stump for 1 sec,
followed by cool down period of 5 seconds
 Pulp stump appears dry & completely blackened
 Chamber filled with ZOE
 Restore with SS crown.

30. Advantages
 The self-limiting pulpal penetration is only a few cell layers deep.
 There is good visualization and hemostasis without chemical coagulation or
systemic involvement.
 Spending less chair time in this technique than the FC pulpotomy is another
benefit

31. Two Visit Pulpotomy
Two-stage procedure.
 Involves the use of paraformaldehyde to fix the entire coronal and radicular pulp
tissue.
 Medicaments and their formulae are as follows :
Gysi Triopaste
 Tricresol 10ml
 Cresol 20ml
 Glycerin 4ml
 Paraformaldehyde 20g
 Zinc Oxide 60g

32. Easlick’s Paraformaldehyde Paste
 Paraformaldehyde
 Procaine base
 Powdered asbestos
 Petroleum jelly
 Carmine
Paraform Devitalizing paste (Modified Easlick’s Paste)
 Paraformaldehyde
 Lignocaine
 Propylene glycol
 Carbowax
 Carmine

33. Indications:
 Inability to arrest haemorrhage from the amputated pulp stumps
during a single visit Formocresol pulpotomy.
 Un-co-operative child behavior.

34. First visit:
 Isolate tooth under rubber dam.
 Prepare the cavity and excavate deep carious dentin.
 When pulp exposure happens during excavation, clear exposed site of the debris.
 Ideally, enlarge exposure with a round bur.
 Incorporate Paraformaldehyde paste into a cotton pellet and place over exposure site.
 Seal the cavity with a thin mix of zinc eugenol and leave for 1-2 weeks.
 Formaldehyde gas liberated from the paraformaldehyde permeates through the coronal and
radicular pulp, fixing the tissues.

35. Second visit :
 Pulpotomy is carried out with the help of LA.
 Roof of pulp chamber removed.
 Clean with saline, dry with a cotton pellet.
 Pulp chamber filled with antiseptic paste and tooth is restored.

36. PRESERVATION PULPOTOMY
 Minimal devitalization/non-inductive pulpotomy
 Maintains maximum vital tissue
 No induction of reparative dentin
 Materials used: Glutaraldehyde
Ferric Sulfate

37. GLUTERALDEYDE PULPOTOMY
 First proposed by Gravenmade,and first used by Kopel
Advantages over Formocresol
1. Superior fixative properties
2. Excellent antimicrobial
3. Less toxic: large molecular size, does not perfuse through the pulp tissue to
the apex
4. Less necrosis of pulp tissue
5. Low systemic distribution
6. Non-mutagenic

38. 7.Low tissue binding, readily metabolized, eliminated in urine & expired in gases.
90% of drug gone in 3 days
8. Formocresol requires a long reaction time & excess solution, where as
Glutaraldehyde fixes tissue instantly and excess solution unnecessary

39. FERRIC SULFATE
 Astringent, not fixative
 Ferric ions from ferric sulfate bind with pulpal proteins and form metal-protein
complexes that mechanically occlude capillaries & produce hemostasis
 Less inflammation than formocresol
 Available in 15.5% solution
 Trade name:Astringedent
 Technique similar to conventional, apply for 10-15 seconds

40.  FS is inexpensive solution and no concerns about toxicity and
carcinogenicity of FS have been recorded in dental literature

41. REGENERATIVE PULPOTOMY
 Also known as Inductive or Reparative pulpotomy
 Stimulates formation of dentin bridge
Materials
 Calcium hydroxide
 Bone morphogenic protein
 MTA
 Enriched collagen

42.  Freeze dried bone
 Osteogenic protein
 Bioactive glass
 Stem cells

43. Non Vital Pulpotomy
(Mortal Pulpotomy)
Indications (Ideally- Pulpectomy)
 When the inflammatory process affecting the coronal pulp extends to the
radicular pulp leading to an irreversible change in the pulp tissue.
 When the pulp is completely non-vital, where there may be an abscess present
with or without acute cellulitis.
 Non-negotiable root canals
 Limited patient co-operation.

44. TECHNIQUE
First visit:
 The necrotic coronal pulp is first removed, using a bur or spoon excavator.
 Pulp chamber irrigated with saline, dried with cotton pellet.
 Infected radicular pulp is treated with a strong antiseptic solution like Beechwood cresol.
 Seal cavity with temporary cement for 1-2 weeks.

45. Second visit:
 Isolate tooth.
 Remove temporary restoration and cotton pellet.
 If symptoms persist – repeat the procedure done in first visit or consider extraction.
 If asymptomatic - the pulp chamber is filled with antiseptic paste.
 This paste can also be firmly pushed into root canals using cotton pellets.
 The tooth can then be restored with a stainless steel crown.

46. FAILURES AFTER VITAL PULP THERAPY
 Internal resorption
 Alveolar abcess
 Pulp canal obliteration

47. THANK YOU