/dr.aravind-odontopediatrician/ topic discusses about management of pulpal pathoses while maintaining the vitality in primary& young permanent teeth.

1. Vital Pulp Therapy
Dr. ARAVINDHAN A,
JR-2,
Dept. of Paediatric & Preventive Dentistry

2. Introduction
 Vital pulp therapy is the treatment initiated on an exposed pulp to
repair and maintain the pulp vitality.
- Grossman
 Pulpal exposure by mechanical or bacterial means leading to
direct communication between pulp and external environment.
 Conservation of tooth in a healthy state.
 Preservation of arch space.
 Enhances esthetics and function.
 Prevents peri radicular infection and its sequalae.

3. contents
 Indirect pulp capping
 Direct pulp capping
 Pulpotomy
 Apexogenesis

4. Indirect pulp capping
 Definition:
“a procedure wherein small amounts of
carious dentin is retained in deep areas of
cavity to avoid exposure of pulp, followed
by placement of suitable medicament and
restorative material that seals off the
carious dentin and encourages pulp
recovery”
-Ingle

5. Objectives of indirect pulp
capping: (Eidelman-1965)
 Arresting the carious process
 Promoting dentin sclerosis
 Stimulating the formation of tertiary dentin
 Remineralisation of carious dentin.
A successful vital pulp treatment requires,
1. a good sealant against bacteria,
2. no severe inflammatory reactions,
3. and stable haemodynamic within the pulp.
- R. Vij, J. A. Coll, P. Shelton, and N. S. Farooq, “Caries control
and other variables associated with success of primary molar
vital pulp therapy,” Pediatric Dentistry, vol. 26, no. 3, pp. 214–
220, 2004.

6. Rationale of IPC

8. Indication contraindication
Mild pain while eating Spontaneous pain
Deep carious lesion with no
pulpal involvement
Pulpo periapical invlovement
Normal periodontium, gingiva
and no mobility
Mobility ,abscess/ fistula .

9. Procedure
Single appointment
procedure
Two appointment
procedure
Under LA and rubber dam
Removal of infected
dentin
Site is covered with
Ca(OH)2
Remainder cavity is filled
with suitable restorative
material
2nd appointment is given after
6-8 weeks of placement of
Ca(OH)2
Re entry of the cavity
Removal of caries if
needed
Placement of Ca(OH)2
Restoration of the
cavity

10.  Indirect pulp capping agent
Titanium
dioxide in
glycol
salicylateCa(OH)2 and
ZnO in ethyl
toluene
sulfonamide
Method of application
Blunt probe Mixing pad

11. Sequalae of IPC
 1. cellular fibrillar dentin – first 2 months
 2. globular dentin- 3 months
 3. tubular dentin- after 3 months (0.1 mm)
Step wise excavation technique
-Re entry of the cavity is done at various intervals
-After Superficial carious lesion is excavated, suitable interim
restoration is done depends on treatment interval (ranges between
6-8 months)
Bjorndal L et al., Indirect pulp therapy and step wise excavation. J
Endod.2008

12. Pulp response to high fluoride releasing glass
ionomer, silver diamine fluoride, and calcium
hydroxide used for indirect pulp treatment: An in-
vivo comparative study- Logani A et al.,JCCD (2015).

14. Direct pulp capping
 “Placement of medicament
or non medicated material on
a pulp that has been exposed in
course of excavating the last
portions of deep dentinal caries
or as a result of trauma.”-Kopel (1992)
 “Procedure in which the exposed vital pulp is covered
with a protective dressing or base placed directly over
the site of exposure in an attempt to preserve pulpal
vitality.”- Grossman.

15. Creation of new dentin in the area of the
exposure and subsequent healing of the pulp

16. Indications
-Small mechanical exposure
-True pin point exposure
-Exposure with bright red hemorrhage
-Asymptomatic vital
primary/permanent tooth
contraindications
-Spontaneous pain
-Tooth mobility
-Uncontrollable bleeding
at exposure site
-External/internal
resorption

17. Technique
Rubber dam isolation
Cavity should be irrigated with saline, chloramine T, or distilled water
Arresting of hemorrhage with sterile cotton pellets in light pressure
Passive placement of pulp capping agent
Temporary restoration
Final restoration of evaluating the success of DPC clinically/
radiologically.

18. Histological changes after DPC
24 hrs
• Necrotic zone adjacent to Ca(OH)2 is separated from healthy
pulp tissue
7 days
• Increase in cellular and fibroblastic activity
14 days
• Disappearance of necrotic zone
• Formation of partly calcified fibrous tissue
28 days
• Zone of new dentin
-GLASS &ZANDER (1949)

19. Histological evaluation of hard tissue formation after direct pulp capping with
a fast-setting mineral trioxide aggregate (RetroMTA) in humans-
Till Dammaschke et al.,JCOI (2019).

20. Limitations of direct pulp capping in
primary tooth
 Internal resorption
 High cellular content
 Faster inflammatory response
 Poor localisation of infection.

21. Materials used for direct
pulp capping
 Calcium hydroxide
 Corticosteroids and antibiotics:
neomycin and hydrocortisone ( Brosch,1966)
ledermix ( Ca(OH)2 and prednisolone).
penicillin/ vancomycin with Ca(OH)2.
 Inert materials:
 isobutyl cyanoacrylate
 tricalcium phosphate ceramic
 Collagen fibres
 4- META adhesives

22.  Direct bonding
 Denatured albumin ( Berkman, 1971)
 MTA
 Bone Morphogenic Protein
 Laser
(laser assisted direct pulp capping has 89% success rate ,1998)

23. Pulpotomy
 “Amputation of the affected or infected coronal
portion of the dental pulp, preserving the vitality &
function of all or part of the remaining radicular
pulp”- AAPD-1998.
VITAL NON- VITAL
•Devitalisation
•preservation
•regeneration
•Mortal pulpotomy

24.  Objectives:
1. removal of inflammed/ infected coronal pulp
2. preserving the vitality of the pulp
3. Maintain the integrity of tge arch
Indications contraindicatons
Mechanical pulp exposure in
primary teeth
Persistent tooth ache
No sinus / fistula Presence of furcal/periapical
infection
Presence of atleast 2/3rd root External /internal
resorption/physiological
resorption of more than 1/3rd of
root
Controllable Hemorrhage from
the exposure site
Uncontrollable sluggish
hemorrhage
No peri radicular pathology Mobilty of tooth

25. Criteria for case selection
 Teeth with deep carious lesion
 Restorable tooth
 No signs of periapical lesion, abscess,
fistula
 No internal/ external resorption
 Hemorrhage should be arrested within 5
minutes from the amputated pulp stumps.
- Heilig J et al.,(1984) & Waterhouse et al., (2000).

26. Formocresol pulpotomy/ single stage
pulpotomy
 Introduced by Buckley (1904).
 Sweet(1930)- multivisit pulpotomy
 Doyle(1962)- two sitting procedure
 Spedding(1965)- 5 minutes protocol
 Venham(1967)- 15 seconds procedure
-Current concept used 4 minutes application time.

27.  Mechanism of action: it prevents tissue
autolysis by bonding to the proteins.
 Composition:
 Cresol- 35%
 Glycerol- 15%
 Formaldehyde- 19%
 Water- 31%

28. Procedure
LA and isolation with rubber dam
Removal of all caries and roof of pulp
chamber
Sharp spoon excavator to scoop out
coronal pulp
Application of formocresol for 4
minutes with cotton pellet
Temporary restoration and replacement
of permanent restoration after 1 week

29. Histological changes after
formocresol pulpotomy
immediate
• Pulp become fibrous and acidophilic
7-14 days
• Broad eosinophilic zone of fixation
• Pale staining zone of atrophy with poor cellular definition
• Broad zone of inflammation extending into vital pulp apically
1 yr
• Progressive apical movement of these zones.
• Only acidophilic zone left after 1 year

30. Comparative evaluation of formocresol and mineral trioxide
aggregate as pulpotomy agents in deciduous teeth-
Daya srinivasan et al., IJDR (2011).

31. Concerns about formocresol
 Toxicity:
Lewis(1981)- cytotoxic, mutagenic and
carcinogenic in animals.
“over 3000 pulpotomies must be done in
an individual to reach the toxic level of
formocresol”.- Ranly.
 Systemic distribution:
formocresol was found in PDL, bone,
dentine, and urine- Myers (1978).
 Antigenocity:
immunogenicity is found with
fromocresol- Thoden valzen (1977).

32.  Mutagenicity and cytotoxicity:
formaldehyde denatures nucleic acids
Formation of methylol compounds
Genetic biosynthesis blockade
(interaction with DNA & RNA)
- Nongentini,1980.
“formaldehyde is not a potent human carcinogen under conditions of low
exposure”
- Milnes et al., persuasive evidence that formocresol use in
pediatric dentistry is safe. J Can Den Assoc.2006

33. Modified formocresol
pulpotomy
 Trask (1972)
 Used in tooth that have to be retained for a
short period of time only
 Technique is identical to primary tooth only
but formocresol, soaked cotton pellet was
kept inside the permanent tooth.

34. Two visit devitalisation
pulpotomy
 Fixation of entire coronal and radicular
pulp tissue by paraformaldehyde in two
visits.
Indications:
 1. sluggish bleeding at the ampuatation
site that is difficult to control.
 2.pus in the chamber but none at the
amputation site
Contraindications:
1. tooth with necrotic pulp.
 2. non restorable tooth.

35. Materials used for 2 visit
pulpotomy
Gysi trio paste Easlicks paraformaldehyde
paste
Paraform devitalising
paste
tricresol paraformaldehyde paraformaldehyde
cresol Procaine base lignocaine
ZOE Powdered asbestos Propylene glycol
glycerin Petroleum jelly carbowax
paraformaldehyde Carmine to color

36. Procedure
LA & isolation
Caries removal &
enlarge the cavity
with round bur
Paraformaldehyde
paste placement and
tempotary restoration
Removal of
the old cotton
pellet
Pulpal
remnants are
removed
restoration
1st visit 2nd visit
After 1-2 weeks
- Nikhil Marwah, 4th edition

37. Gluteraldehyde pulpotomy
 Kopel-1979
 Mechanism:
-rapid surface fixation of pulpal tissue.
-blends into vital normal apical tissue.
-fixed tissue is replaced by dense collagenous
tissue with time.
- 2% gluteraldehyde is applied for 1-3 minutes
over the ampuated pulp. (garcia & godoy ,1986)

38. Adavntages over formocresol…
 1.superior fixation by protein cross linkage.
 2. excellent antimicrobial.
 3. less necrosis of pulp
 4. doesn’t perfuse through apex.
 5. less mutagenicity and antigenicity.

39. Ferric sulphate pulpotomy
 Method of application is similar to formocresol
pulpomy.
 15.5% concentration of solution is applied for
15 seconds.
 Mechanism: agglutination of blood proteins
results from the reaction of blood with both
ferric and sulphate ions.
-agglutinated proteins form plugs to
occlude capillary orifice.
 Minimises the chance of internal resorption.
“Controlled clinical studies have been critically
reviewed, and mineral trioxide aggregate and ferric
sulfate have been considered appropriate alternatives
to formocresol for pulpotomies in primary teeth with

40. Laser pulpotomy
 Ebimara-1985 used Nd-YAG laser in
pulpotomy at 20Hz.
Coronal pulp is removed with spoon
excavator
Laser is applied at pulp stumps for not
more than 2-3 minutes
restoration
Diode laser
810 nm
3W power
Non contact
mode
Continuous
wave

42. “Postoperative assessment of diode laser zinc oxide eugenol and
mineral trioxide aggregate pulpotomy procedures in children: A
comparative clinical study”- Pratima I et al., JISPPD (2018).

43. Cvek pulpotomy
 Partial pulpotomy/ calcium hydroxide
pulpotomy
 Mejare & cvek-1978
 Indicated in young permanent tooth
where the radicular pulp is judged vital
by clinical/ radiological criteria and
root formation is incomplete.
 According to American Academy of
Pediatric Dentistry (AAPD) guidelines,
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 or more to reach the deeper
healthy tissue.

44. All carious tooth structure is removed
Part of coronal pulp is removed
Ca(OH)2 is applied
Temporary
restoration
Asymptomatic during recall
Permanent restoration

45. Non vital pulpotomy
 Mortal pulpotomy
 Non vital tooth should be treated with pulpectomy,
but sometimes it is impracticable due to non
negotiable root canals. Mortal pulpotomy is done in
such patients.
 Beechwood cresol is used in this procedure.
 If the tooth is asymptomatic after 1-2 weeks ,
definite restoration is given.

46. Current concepts in pulpotomy…
 MTA pulpotomy
 Portland cement
 Nano hydroxy apatite and BMP
 Calcium enriched mixture
 Allium sativum oil
 Lyophilised freeze dried platelet with calcium hydroxide.
 Enamel matrix derivative
 Propolis
 Ankaferd blood stopper
 Platelet rich plasma
 Pulpotec
 Calcium phosphate cement
 Biodentine

47. -Journal of conservative dentistry,(2015)

50. Apexogenesis
 It is defined as “the treatment
of a vital pulp by capping or
pulpotomy in order to permit
continued growth of the root and
closure of the open apex”.
 Rationale:
maintanence of integrity of the
radicular pulp tissue to allow for
continued growth.

51. Procedure
LA & isolation
Removal of carious tooth structure
Removal of coronal pulp and control
of hemorrhage
Ca(OH)2 is placed over the pulp
stumps
Periodic follow up to check the root
development

52. -PJ Van der vyver et al., SADJ (2018)

54. Thank you!