PULPOTOMY IN PRIMARY TEETH

1. PULPOTOMY BY- Dr. SUMEET VINCENT TIGGA (G.D.C RAIPUR)

2. DEFINATION-: 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 )

4. Vital tooth with healthy periodontium

5. Pain, if present not spontaneous nor persists after removal of the stimulus

6. Tooth which is restorable

7. Tooth with-2/3rd root length

8. Hemorrhage from the amputation site is pale red & easy to control

10. CONTRAINDICATION -: Evidence of internal resorption Presence of inter radicular bone loss Abscess , fistula in relation to teeth Radiographic sign of calcific globules in pulp chamber Caries penetrating the floor of pulp chamber Tooth close to natural exfoliation

12. 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

13. 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.

14. .. To prepare a 1:5 conc. Of this formula- First thoroughly mix 3 part of glycerinre with 1 part of distilled water Then add 4 parts of this preparation to 1 part Buckley’s formocresol & thoroughly mix again Mechanism Of Action:Formocresol prevents tissue autolysis by bonding to protein. This is reversible process and is accomplished without changing the basic overall structure of the protein molecules

15. Technique for Pulptomy of thePrimary Teeth 1. Profound anaesthesia for tooth and tissue. 2. Isolate the tooth to be treated with a rubber dam. 3. 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

16. . 6. Achieve heamostasis with moist cotton pellets under pressure. 7. Apply diluted formocresol to pulp on cotton pellet for 3- 5 minutes. Pressure on pellet. 9. Pulp chamber is dried with new cotton pellets . 10. Place a thick paste of ZOE in contact with pulp stumps. 11. Place stainless steel crown (or bonded composite)

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20. 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 .Thickened PDL

21. ` 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

22. . 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

23. .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

24. .Second appointment In the second appointment pulpotomy is carried with the help of L.A. 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.

25. PARTIAL PULPOTOMY The partial pulpotomy for traumatic exposures is a procedure in which the 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

26. OBJECTIVES FOR Ca(OH)₂ PULPOTOMY OF YOUNG PERMANANT 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

27. PROPERTIES OF CALCIUM HYDROXIDE Calcific bridge formation(91% success) Germicidal activity Vital pulp remains Clinical success to be 65% Hystological success 35%

28. CLINICAL TECHNIQUE FOR THE Ca(OH)₂ PULPOTOMY 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

29. . 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.

30. 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

31. 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 sulfatedihydrate.

32. . 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.

33. 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 pulpotomy technique is advocated .

34. SELECTION CRITERIA History of spontaneous pain Swelling ,redness or soreness of mucosa Tooth mobility Tenderness to percussion Radiographic evidence of root resorption

35. TCHNIQUE 1ST APPOINTMENT - NECROTIC PULP IS REMOVED - PULP CHAMBER IS IRRIGATED WITH SALINE & DRIED WITH COTTON PELLET -RADICULAR PULP IS TREATED WITH BEACH WOOD CERSOL DIPPED COTTON PELLET -SEAL THE CAVITY WITH TEMP. CEMENT FOR 1-2 WEEKS

36. 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 B RESTORED WITH STAINLESS STEEL CROWN

37. ELECTROSURGICAL PULPOYOMY > Mack & Dean,1993 > Non-pharmacological technique > Non-chemical devitalisation , hear electrocautery carbonized & heat denatures the pulp & bacterial contamination

38. . > After amputation of the coronal pulp , the pulp stumps are cauterized through this method. 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

39. LASER PULPOTOMY: > Non- pharmocologichemostatic 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,

40. PRESERVATION Chemicals which induce minimal insult to the tissue are used. They help to conserve vitality of the radicular pulpChemicals 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; IN HIGHER CONC. FOR LONGER EXPOSURE GLUTERALDEHYDE SHOWS CYTOTOXIC & MUTAGENIC EFFECTS SAME AS FORMOCRESOL

41. . Ferric sulfate- It is a non aldehyde haemostatic compound(1)astringent; (2)forms a ferric ion-protein complex that mechanically occludes capillaries; (3) less inflammation than formocresol(4) 92.7% radiographic success rate.(5)100% clinical success(6)root resorption is not accelerated (7)internal resorption similar to formocresol ,no systemic or local side effects

42. 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(bone morphogenic protein) 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)

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