A pulpotomy involves removing the inflamed coronal pulp while leaving the healthy radicular pulp intact. The aim is to relieve pain and allow for root development. Formocresol pulpotomy is commonly used and involves applying formocresol to the exposed pulp stump to fix tissues and eliminate microorganisms. It is performed using either a single-stage or two-stage technique. Other materials used include calcium hydroxide, glutaraldehyde and ferric sulfate. Success rates depend on strict case selection and technique.

1. PULPOTOMY PROCEDURES IN PRIMARY DENTITION

2. index Definition Classification Technique Formocresol pulpotomy Ca(OH) 2 pulpotomy Other procedures Summary References

3. A pulpotomy is defined as the surgical removal of the entire coronal pulp pre-sumed to be partially or totally inflamed and quite possibly infected, leaving intact the vital radicular pulp within the canals . The aim is to relieve pain due to pulpalgia and leave the vital pulp in roots for its completion , if incomplete (apexogenesis ) DEFINITION

4. classification Pulpotomy Partial pulpotomy complete pulpotomy calcium hydroxide formocresol pulpotomy pulpotomy

5. CLASSIFICATION Non vital pulpotomy Vital pulpotomy Beechwood cresol Devitalization Formocresol Preservation Regeneration

6. Vital pulpotomy technique Devitalization Preservation Glutaraldehyde Ferric sulphate Regeneration Bone morphogenetic protein Dentin chips Single sitting – Formocresol Electrosurgery Laser Two stage – Gysi triopaste Easlick’s formaldehyde Paraform devitalising pastePreservation

7. Formocresol pulpotomy Formocresol was introduced in 1904 by Buckley, who contended that equal parts of formalin and tricresol would react chemically with the intermediate and end products of pulp inflammation to form a “ new, colorless, and non-infective compound of a harmless nature.” Buckley’s formula formocresol, consists of tricresol, 19% aqueous formaldehyde, glycerine, and water.

8. indications Carious / mechanical exposure in vital asymptomatic tooth Tooth free of radicular pulpitis Presence of atleast 2/3 rd root length Absence of abscess or fistula. Absence of inter radicular bone loss Absence of internal root resorption Permanent posterior teeth for the expedient treatment of pulpalgia. (it relieves pain in emergency as formocresol fixes the contiguous pulp left in the root canal.)

9. Contraindications Local : - Spontaneous pain / pain at night Pathologic mobility Swelling or fistula Internal resorption Less than 2/3 rd root remaining Periapical inter radicular radiolucency Pus / serous exudate at exposure site Uncontrolled haemorrhage from amputed pulp Excesive pulp calcification Medical : - Cardiac condition Immunocompromised children

10. TECHNIQUE The formocresol pulpotomy technique was first advocated by SWEET [1930] He used a multiple sitting technique, which has been subsequently modified to either a single or two stage technique. FORMULA :- 19% Formaldehyde 35% cresol 15% Glycerin & Water To prepare 1.5%concentration of this formula, first mix 3 parts of glycerin with 1 part of distilled water , then add 4 parts of this preparation to 1 part buckley’s formocresol , and throughly mix again.

11. Mechanism of action Formocresol causes coagulation necrosis in tissues in immediate vicinity of the application with fixation of tissue cells and micro organism.

12. One-Appointment Pulpotomy. Indications :- only on those restorable teeth in which it has been determined that inflammation is confined to the coronal portion of the pulp. Contraindications :- Teeth with a history of spontaneous pain Profuse haemorrhage Pathologic or internal root resorption Inter radicular bone loss Presence of fistulas or pus in the chamber

13. PROCEDURE Anesthetize the tooth and tissue.

14. Isolate the tooth with rubber dam

15. Remove caries & determine site of pulp exposure Remove roof of pulp chamber

16. Remove coronal pulp with a large excavator or a large round bur

17. Apply formocresol on the pledge of cotton wool for 4 minute

18. Remove formocresol pledget after 4 min. & check that haemorrhage has stopped Fill pulp chamber with cement

19. Restore the tooth with stainless steel crown

20. Take a post operative photograph

21. Two-Appointment Pulpotomy. Indications (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 (5) A history of spontaneous pain without other contraindications. Contraindications. (1) Nonrestorable (2) Soon To Be Exfoliated (3) Necrotic.

22. Procedure 1. The steps are the same as for the one-appointment procedure 2. A cotton pellet moistened with diluted formocresol is sealed into the chamber for 5 to 7 days with a durable temporary cement. 3. At the second visit, the temporary filling and cotton pellet are removed and the chamber is irrigated with hydrogen peroxide. 4. A ZOE cement base is placed. 5. The tooth is restored with a stainless steel crown.

23. Partial pulpotomy (pulp curretage ) It is removal of coronal pulp tissue up to the level of healthy pulp. This process is also known as partial pulpotomy. INDICATIONS : -- when zones of inflammation has extended more than 2 mm. in an apical direction but has not reached root pulp. Eg. A traumatic exposure (a few days post injury in a large young pulp)

24. TECHNIQUE Area is anaesthetised and isolated A 2 mm. deep cavity is prepared into pulp using sterile diamond bur and copius water coolent Excess blood is removed by saline & small cotton pelletes Calcium hydroxide is placed onto cavity Sealed with ZOE reinforced IRM restoration. IT IS RARELY SUCESSFUL AND HENCE HAS NO CLINICAL SIGNIFICANT.

25. REASONS FOR FAILURE Pulp is highly vascular so, even with slightest infection in any corner of pulp , the whole of it gets infected very quickly. Its practically impossible to remove one part of coronal pulp without disturbing the other parts of it in pulp chamber.

26. DEVITALIZATION PULPOTOMY It is two stage procedure involving the use of paraformaldehyde to fix the entire coronal & radicular pulp tissue. The medicament used have a devitalizing, mummifying, & bactericidal action.

27. TECHNIQUE First appointment :- Same as formocresol pulpotomy but place the paraformaldehyde paste in cotton pellete over the exposure & seal the tooth for 1 to 2 weeks. Formaldehyde gas liberates from the paraformaldehyde permeates through the coronal and radicular pulp, fixing the tissue. Second appointment :- pulpotomy is carried out with the help of local anaesthesia

28. ELECROSURGICAL PULPOTOMY Given by mack & dean (1933 ) It is a non chemical devitalizaton technique. Electrocautery carbonizes and heat denatures the pulp & bacterial contamination After amputation of coronal pulp,the pulp stumps are cauterized through this method

29. Laser pulpotomy Jeng-fen liu et al in 1999 studied the effect on Nd:YAG laser for pulpotomy in primary teeth

30. Glutaraldehyde by kopel (1979 ) Advantages over formocresol Superior fixative property Self limiting penetration Low antigenicity Low toxicity Elimination of cresol 2-5 % concentration

31. Ferric sulphate It forms a metal protein clot at the surface of the pulp stump and this act as a barrier to irritating components of the sub-base

32. references Restorative technique for paediatric dentistry - Ms DUGGAL, MEJ CURZON, SA FAYLE, KJ TOUMBA, AJ ROBERTSON Endodontic – Fifth Edition - JOHN I. INGLE, LEIF K. BAKLAND Text Book Of Pedodontics - SHOBHA TANDON Clinical Pedodontics - FINN INTERNET ( www.google.com)