Vital Pulp Therapy

Presented By:
Dr Susmita Shah
II MDS
Vital Pulp Therapy in
Primary & Permanent Teeth
1

Contents
Introduction
Indirect pulp capping
Direct pulp capping
Pulpotomy
Conclusion
Bibliography
2

INTRODUCTION
• Exposure of the dental pulp exists when the continuity of the dentin
surrounding the pulp is broken by physical or bacterial means leading to
direct communication between the pulp and external environment.
• The primary objective of pulp therapy is to maintain the integrity and health
of the teeth and their supporting tissues.
• It is a treatment objective to maintain the vitality of the pulp of a tooth
affected by caries, traumatic injury, or other causes.
•John I. INGLE,DDS,MSD Ingle’s
Endodontics 6th Edition.
3

OBJECTIVES
• Conservation of tooth in a healthy state of functioning
• Preservation of arch space
• Enhance aesthetics
• Mastication
• Prevents possible speech problems
• Prevention of deleterious effect on the succedaneous tooth and the
periapical tissue.
• Prevents aberrant tongue habits
• Preserves pulpally involved primary tooth in the absence of a succedeneous
tooth
• Guidance to the developing permanent dentition
• Helps in normal growth and development of jaws
Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY OF
PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014.
4

• The clinical diagnosis is derived from:
1. a comprehensive medical history.
2. a review of past and present dental history and treatment
3. a subjective evaluation of the area associated with the current
symptoms/chief complaint by questioning the child and parent on the
location, intensity, duration, stimulus, relief, and spontaneity.
4. a objective extraoral examination as well as examination of the
intraoral soft and hard tissues.
5. if obtainable, radiograph(s) to diagnose pulpitis or necrosis showing
the involved tooth, furcation, periapical area, and the surrounding
bone.
6. clinical tests such as palpation, percussion, and mobility
5

Dental Caries or physical/ thermal/
chemical injury
Pulpal Irritation
Inflammation
Reversible
Repair Necrosis
Irreversible
Vital pulp therapy
6

VITAL PULP THERAPY
PRIMARY TEETH PERMANENT TEETH
INDIRECT PULP
CAPPING
DIRECT PULP CAPPING
PULPOTOMY
INDIRECT PULP CAPPING
DIRECT PULP CAPPING
PULPOTOMY
APEXOGENESIS
7

• INDIRECT PULP CAPPING
• Definition:
It is defined as a procedure wherein small amount of carious dentin is
retained in deep areas of cavity to avoid exposure of pulp, followed by
placement of a suitable medicaments and a restorative material that seals off
the carious dentin and encourages pulp recovery(Ingle)
• A procedure in which only the gross caries is removed from the lesion and
the cavity is sealed for a time with a biocompatible material(McDonald).
8

OBJECTIVES
• Given by eidelman in 1965:
1) arresting the carious process
2) promoting dentin sclerosis
3) stimulating formation of tertiary dentin
4) remineralization of carious dentin
•John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 9

10

History Clinical Examination Radiographic
Examination
Indication Mild pain associated
with eating
Negative history of
spontaneous, extreme
pain
-Deep carious lesion that are
closed to pulp, but not
involving the pulp in vital
primary or young permanent
teeth
-No mobility
-Where pulp inflammation is
seen as nominal and there is
definite layer of affected
dentin after removal of
infected dentin
-Normal lamina Dura
and PDL space
-No radiolucency in the
bone around the
apices of the roots in
the furcation
Contraindication -Sharp penetrating
pulpalgia indicating
acute pulpal
inflammation.
-Prolonged
spontaneous pain
particularly at night.
-Mobility of tooth
-Discoloration of tooth
-Negative reaction of electric
pulp testing
-Definite pulp exposure
-Interrupted or break in
lamina dura
-Radiolucency about
the apices of the roots
-Widened PDL space
11

TREATMENT PROCEDURE
• The earlier approach was 2 appointment procedure but now single session
is preferred as;
 The re-entry to remove the residual minimal carious dentin may not be necessary if the
final restoration maintains a seal and tooth is asymptomatic
 After cavity preparation, if all the carious dentin was removed except the portion that would
expose the pulp, re entry might be unnecessary.
 If a pulp exposure occurs during a re-entry a more invasive vital pulp therapy technique
would be indicated.

 1st appointment
1) use LA and rubber dam isolation
2) establish cavity outline
3) remove all caries using caries detector dye, infected dentin has to be removed
4) stop excavation as soon as firm resistance sound dentin is felt
5) if there is probability of exposure while removing further caries, then a
conservative approach is chosen by placing a hard set calcium hydroxide and
temporizing the tooth
6) cavity flushed with saline and direct with cotton pellet
7) site is covered with Ca(OH)2
8) remaining cavity is filled with ZOE cement

 2nd appointment (6-8 weeks later)
1) between the appointment history must be negative
2) If a reparative dentin bridge is formed, a permanent restoration followed by a full
coverage restoration is chosen
3) If some amount of caries present on re-entry, carefully removal of caries, without pulp
exposure.
4) Previous remaining carious dentin will have become dried out, flaky and easily removed
5) The cavity preparation is washed out and dried gently
6) Cover entire floor with Ca(OH)2
7) Base is built up with reinforced ZOE cement or GIC
8) Final restoration is then placed
•John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition.
14

Parisay I, Ghoddusi J, Forghani M. A Review on Vital Pulp Therapy in Primary Teeth. Iranian
Endodontic Journal 2015;10(1):6-15
15

Akhlaghi N, Khademi A. Outcomes of vital pulp therapy in permanent teeth with different medicaments based
on review of the literature. Dental Research Journal / September 2015 / Vol 12 / Issue 5
16

17
Title Author
Journal
L
O
E
Aim Materials and
methodology
Results Conclusion
Material
s used
for
indirect
pulp
treatme
nt in
primary
teeth: a
mixed
treatme
nt
compari
sons
meta-
analysis
Pablo
Silveir
a dos.
Djessi
ca,
Minate
l M,
Oliveir
a R,
Lariss
a T.
Braz.
Oral
Res.
2017;
31:e1
01
1
a
to
systematical
ly review the
literature to
address the
question
regarding
the
influence of
different
materials
in the
clinical and
radiographic
success of
indirect pulp
treatment in
primary
teeth.
A comprehensive
literature search was
undertaken
using
PubMed/MEDLINE,
Cochrane Central
Register
of Controlled Trials
(CENTRAL),
Scopus, and TRIP
databases to identify
studies that were
related to the
research question
and that were
published prior to
January 2017.
The material
type did
not
significantly
affect the risk
of failure of
the indirect
pulp
treatment.
However,
calcium
hydroxide
presented a
higher
probability of
failure.
In
conclusion, there
is no scientific
evidence showing
the superiority of
any
material used for
indirect pulp
treatment in
primary teeth

John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition.
18
The rate of reparative dentin deposition has been shown to average
1.4um/day after cavity preparation in dentin of human teeth.
The rate of reparative dentin formation decreases markedly after 48days.
Dentin is laid down fastest during the first month after IPC and the rate
diminishes steadily with time.
First 30 days- 1/5th Tubular dentin is formed
First 2 months- Cellular fibrillar dentin is formed
Third month- Globular dentin is formed
More than3 months- 0.1mm Tubular dentin is formed

19
Title Author
Journa
l
L
O
E
Aim Materials and
methodology
Results Conclusion
In vivo
Outco
mes of
Indirect
Pulp
Treatm
ent in
Primar
y
Posteri
or
Teeth:
6
Months
’
Follow-
up
Chau
han A,
Dua
P,
Saini
S,
Mangl
a R,
Butail
A,
Ahluw
alia S.
Conte
mpora
ry
Clinic
al
Dentis
try
2018
3
b
to evaluate &
compare the
clinical
&radiographic
outcomes of
IPT
when a layer of
calcium
hydroxide
(Dycal),
mineral trioxide
aggregate
(MTA), or
Biodentine was
placed over the
affected dentin
in primary
molars
A clinical trial with
sample size of 45
primary molars
between the age
group of 4–9
years, of which 15
teeth were
considered, each
for Group I
(Dycal), Group II
(MTA), and
Group III
(Biodentine).
Measurements
on digitized
radiographs were
made at baseline,
3, and 6 months
using Corel Draw
software
a statistically
significant difference
in dentin
thickness (P < 0.05)
in all the groups.
Within Group I, the
thickness of dentin
was 0.066 ± 0.009
mm
at 3 months and
0.099 ± 0.011 mm at
6 months. In Group
II, 0.081 ± 0.010 mm
at 3 months and
0.123 ± 0.016 mm at
6 months. In Group
III, 0.102 ± 0.021
mm at 3 months and
0.154 ± 0.022 mm
at 6 months.
Clinically,
100% success
rate was
observed in all
the groups
whereas
radiographicall
y, Biodentine
was superior
to both the
groups.

20
1. Biodentine
2. Stem cells
3. Propolis
4. Theracal LC
5. Caster oil Bean Cement
6. Emdogain
7. Novel Endodontic Cement
8. Lasers
9. Endo Sequence root repair material

• DIRECT PULP CAPPING
22
The first method of capping exposed pulps, using gold foils,
was described by Pfaff in 1756. Thereafter, numerous agents
for direct pulp capping have been recommended.
Until the end of the 19th century, most materials were used
empirically with the idea that the pulp tissue must be irritated
by etching or cauterization to heal.
Hunter(1883) suggested 1st pulp capping materials. He
recommended covering an exposure with a mixture of
Sorghum molasses and the droppings of the English sparrow
and claimed 98% success rate
The first scientific clinical study to compare different capping
materials was made by Dätwyler in 1921, whereupon zinc
oxide-eugenol showed the best results.
One year later, Rebel performed the first animal experiments
with disastrous results, so he regarded the he regarded the
exposed pulp as a doomed organ.

23
In 1920 Hermann, introduced calcium hydroxide for root canal
fillings. Between 1928 and 1930 he studied the reaction of vital
pulp tissue to calcium hydroxide to prove that it was a
biocompatible material.
Since then, calcium hydroxide has been recommended by several
authors for direct pulp capping, but it took until the middle of 20th
century until it was regarded as the standard of care.
Placement of a medicated or a nonmedicated material on a pulp
that has been exposed in the course of preparing a cavity in a
carious tooth or as the result of trauma.[Kopel, 1997]

OBJECTIVE
a) preservation of vitality of the pulp
b) Pulp healing and reparative dentin formation
24
RATIONALE
• To achieve a biologic closure site by deposition of hard
tissue barrier between pulp tissue and capping material thus
walling off the exposure site

INDICATION
• Small mechanical exposure
surrounded by sound
dentin is asymptomatic
vital primary teeth or young
permanent teeth(1sq mm)
• Exposure should have
bright red haemorrhage that
is easily controlled by dry
cotton pellet with minimal
pressure
• True pin point exposure
• Traumatic exposure
reported to dental office-
within 24 hours.
Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY OF PEDIATRIC
DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014.
25
CONTRAINDICATIONS
• Large pulp exposure
• Severe toothache at night
• Spontaneous pain
• Tooth mobility
• Radiographic appearance of
pulp, periradicular
degeneration
• Excess of haemorrhage at the
time of exposure
• Serous exudate from the
exposure
• External/internal root
resorption
• Swelling/fistula
• Tooth mobility

TECHNIQUE
• Rubber dam isolation
• Once an exposure is encountered, further manipulation of pulp is
avoided
• irrigation with saline
• Hemorrhage is arrested with light pressure from sterile cotton pellets
• Place the pulp capping material, on the exposed pulp with application of
minimal pressure so as to avoid forcing the material into pulp chamber
• Place temporary restoration
• Final restoration is done after determining the success of pulp capping
which is done by determination of dentinal bridge.
• Maintenance of pulp vitality, lack of pain, and minimal inflammatory
response.
John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition.
26

27Akhlaghi N, Khademi A. Outcomes of vital pulp therapy in permanent teeth with different medicaments based

Outcome of Direct Pulp Capping
• Acc. To Kennedy & Kopel (1985):
• Dentin bridge formation
• Maintenance of pulp vitality
• Lack of undue sensitivity or pain
• Minimum pulpal inflammation response
• Ability of pulp to maintain itself without progressive degeneration
• Lack of internal resorption and/ or interradicular pathosis
John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 28

Ideal requirements of pulp capping agents
1. Bactericidal
2. Biocompatible
3. Harmless to the pulp, surrounding structures
and the permanent tooth germ.
4. Promote healing
5. Not interfere with physiologic process of
resorption.

Liang CHEN and Byoung In SUH. Cytotoxicity and biocompatibility of resin-free and resin-modified
direct pulp capping materials: A state-of-the-art review. Dental Materials Journal 2017; 36(1): 1–7.
30

1. CALCIUM HYDROXIDE
• Colorless crystal or white powder
• Prepared by reacting calcium oxide with water.
• Hermann (1920-1930): use of calcium hydroxide in endodontics
• Most favored as a pulpotomy agent in the 1940s and mid- 1950s.
• Teuscher and Zander(1938): Ability to form reparative dentin this
• Lim and Kirk(1987): review of direct pulp capping literature, found
little support for pulp obliteration and internal resorption being a
major complication of pulp capping
• Estrela et al(1995). summarized the antibacterial properties of
calcium hydroxide.
31

• Base paste –
• Glycol salicylate-40%-reacts with
• Calcium hydroxide and ZnO
• Titanium dioxide-Inert fillers
• Calcium tungstate - Fillers
• Barium sulphate-provide radio-opacity
• Catalyst paste
• Calcium hydroxide-50%-principal reactive ingredient
• Zinc oxide-10%
• Zinc stearate-0.55%-accelerator
• Sulphonamide-39.5%-oily
• compound acts as carrier.

• Advantages
• Reparative dentin formation
• Antibacterial action
• Pulp protection
• The tissue-dissolving property
• Newer preparation shows
Improved strength, essentially
no solubility in acid, and
minimal solubility in water and
control the over working time
• Disadvantages
• Pulp obliteration
• Internal resorption
• Lack of adhesion to hard
tissues
• Microleakage
• Short working time of self
cured preparation
• Disadvantages
• Pulp obliteration
• Internal resorption
• Lack of adhesion to hard
tissues
• Microleakage
• Short working time of self
cured preparation

HISTOLOGICAL CHANGES
• After 24 hrs: necrotic zone
adjacent to calcium hydroxide
paste is separated from healthy
pulp tissue by a deep staining
basophilic layer
• After 7 days: increase in cellular
or fibroblastic activity
• After 14 days: partly calcified
fibrous tissue lined by
odontoblastic cells is seen below
the calcium protienate zone;
disappearance of necrotic zone
• After 28 days: zone of new dentin

2. Mineral Trioxide Aggregate (MTA)
• Pioneered by Dr. Mahmoud Torabinejad, Loma Linda University, in
1993.
• COMPOSITION
• MTA is a mechanical mixture of 3 powder ingredients:
• Portland cement (75%)
• Bismuth oxide (20%)
• Gypsum (5%)
• Composition includes :
• Tricalcium silicate
• Dicalcium silicate
• Tricalcium aluminate
• Tetracalcium aluminoferrite
• Calcium sulfate
• Bismuth oxide (provides radio-opacity)
TJ Hilton. Keys to Clinical Success with Pulp Capping: A Review of the
Literature Oper Dent. 2009 ; 34(5): 615–625.
35

36
• Advantages
• Antimicrobial Activity
• Prevents Micro-Leakage over vital
pulp
• Non toxic and Non-mutagenic
• Cell adherence & growth
• Alkaline phosphotase/ osteocalcin
• Interleukin production
• Periodontal ligament attachment to
cementum growth
• Dentinal bridge formation
• Disadvantages
• More difficult to manipulate
• Longer setting time
• Properties
• Powder: Water = 3: 1
• SETTING TIME: 3-4 hours
• pH=12.5

37
Title Auth
or
Jour
nal
L
O
E
Aim Materials and methodology Results Conclusion
Direct
Pulp
Cappin
g with
Calciu
m
Hydrox
ide or
Minera
l
Trioxid
e
Aggreg
ate: A
Meta-
analysi
s
Li
Z,
Cao
L,
Fan
M,
Xu
Q.
Jou
rnal
of
End
odo
ntic
s.
201
5
1
a
to
compare
the
effectivene
ss of
mineral
trioxide
aggregate
(MTA) and
calcium
hydroxide
(CH) as
pulp
capping
materials
in humans
by means
of a meta-
analysis.
The PubMed, Cochrane
Library, Embase, and
Web of Knowledge
databases were used in
the literature search from
their establishment date
until December 7, 2014.
Studies that met the
inclusion criteria were
accepted, and necessary
information was
extracted
by 2 authors
independently using a
standardized
form. The success rate,
inflammatory response,
and
dentin bridge formation
were evaluated.
Thirteen
studies met the
inclusion
criteria. The
MTA treatment
groups showed
a significantly
higher success
rate compared
with CH-
capped groups.
MTA was
superior to CH
in terms of the
absence of an
inflammatory
response as
well as dentin
bridge
formation,
MTA has a
higher
success
rate
and results
in less
pulpal
inflammato
ry
response
and
more
predictable
hard dentin
bridge
formation
than
CH.

3. Zinc Oxide eugenol
• Germicidal agent
• Used in indirect pulp capping due to its
– Palliative effect
– Excellent initial seal
– Kills bacteria present in carious lesions
– arrests the caries process
• This gives the pulp the chance for healing & regeneration
• Direct contact →chronic inflammatiom,abscess formation and
liquefaction necrosis.
• After 24Hr of capping →a mass of red blood cells &PNLs.
demarcated from the underlying tissue by zone of fibrin and
inflammatory cells.
• After 2W of capping → pulp degeneration &chronic inflammation
• extends deep to the apex.

4. Lasers
• Used in Direct pulp capping & pulpotomy.
• Co2 Laser , Argon Laser, Diode Laser, Erbium:Yttrium-Aluminum
Garnet (Er.YAG).
• Laser radiation has been proposed for pulp treatment based on its
haemostatic, coagulative and sterilizing effects.
• Laser irradiation creates a superficial zone of coagulation necrosis
that remains compatible with the underlying tissue and isolate pulp
from effects of the subbase.
• Mortiz et al., reported that the thermal effects of laser radiation
caused sterilization and scar formation in the irradiated area, which
in turn preserves the pulp from bacterial invasion.
39

40
Title Author
Journa
l
L
O
E
Aim Materials and
methodology
Results Conclusion
Laser
use in
direct
pulp
cappin
g: A
meta-
analys
is
Deng
Y, Zh
u
X, Zh
eng
D, Ya
n
P, Jia
ng H.
J Am
Dent
Asso
c. 20
16
Dec
3
b
to
evaluate
the effects
of lasers
on the
outcome
of direct
pulp
capping
by means
of a meta-
analysis
a literature search on
PubMed, Cochrane
Library, Embase, and
China National
Knowledge
Infrastructure, as well
as a manual search of
the reference lists of
all identified articles
since the introduction
of lasers in
endodontics in 1971
through May 30,
2016. The authors
systematically
evaluated the studies
that met the inclusion
criteria and performed
a meta-analysis.
results showed
that the success
rate (89.9%) of
the laser groups
was higher than
that of 67.2% of
the control
groups, and the
difference was
statistically
significant (risk
ratio, 1.35; 95%
confidence
interval, 1.23-
1.49; P <
.00001).
On the basis
of the limited
evidence, the
use of lasers
effectively
improved the
prognosis of
direct pulp
capping
treatment for
permanent
teeth.

5. Biodentine
• Biodentine (Septodont, Lancaster, PA, USA), launched in 2009
• Composition:
– tricalcium silicate
– Calcium Carbonate
– Calcium Oxide
– zirconium oxide (radiopacifier)
• mixed with calcium chloride solution containing modified
polycarboxylate instead of water
• setting times (from 10 to 12 min).
41

42
Title Author
Journa
l
L
O
E
Aim Materials and
methodology
Results Conclusion
Clinical
evaluat
ion of
minera
l
trioxide
aggreg
ate
and
bioden
tine as
direct
pulp
cappin
g
agents
in
carious
teeth
Hegd
e S,
Math
ew S,
Bhan
di S,
Naga
raja
S, K.
Dine
sh.
2017
Journ
al of
Cons
ervati
ve
Denti
stry
3
b
The aim
of the
present
study was
to
evaluate
the
clinical
response
of
pulp-denti
n complex
after DPC
with MTA
and
biodentine
in carious
teeth.
Twenty-four
permanent molars
with carious exposure
having no signs and
symptoms of
irreversible
pulpitis were selected
and assigned to one
of the two groups,
Group I - MTA and
Group II - biodentine.
Patients were
recalled at 3 weeks, 3
months, and 6 months
for clinical and
radiographic
evaluation. Fisher’s
exact test was used
along
with Chi-square test
for statistical analysis.
Over a period of
6 months, MTA
and biodentine
showed 91.7%
and 83.3%
success rate,
respectively,
based on the
subjective
symptoms, pulp
sensibility tests,
and
radiographic
appearance.
MTA and
biodentine
may be used
as DPC
agents when
the pulpal
diagnosis is
not more
than
reversible
pulpitis.

43
Pulp Capping agents Advantages Disadvantages
Calcium Hydroxide Antibacterial properties
Promotes remineralization
Low Cytotoxicity
Highly soluble in oral fluids
Tunnel defect
Lack of adhesion
Zinc Oxide Eugenol Reduces inflammation Lack of calcific bridge
formation
High cytotoxicity
Interfacial leakage
Polycarboxylate
Cements
Chemically bond to tooth surface Lack of antibacterial activity
Fail to stimulate calcific
barrier
Inert
Materials(Isobutyl
Cyanoacrylates &
Tricalcium Phosphate
Ceramic
Stimulates dentin bridge
formation
Reduces pulpal inflammation
Not recommended by
dentists
Collagen Less irritating than calcium
hydroxide
Promotes remineralization
Do not help in thick dentin
formation

44
Bonding agents Superior adhesion to hard tissues
Effective seal against micro
leakage
Cytotoxic effect
Absence of calcific bridge
formation
Calcium phosphate Helps in bridge formation
Significant absence of pulp
inflammation
Good physical properties
Clinical trials are necessary
Hydroxyapatite Biocompatible
Acts as scaffold for newly formed
dentin
Mild pulpal inflammation
Carbon dioxide laser Formation of secondary dentin
Bactericidal effect
Technique sensitive
Thermal damage
Glassionomer /Resin
Modified glassionomer
cement
Excellent seal
Fluoride release
Biocompatible
Chronic inflammation
Lack dentin bridge
formation
High Cytotoxic activity
Mineral trioxide
aggregate
Biocompatible
Less pulpal inflammation
Hard tissue barrier formation
Radiopacity
Expensive
Poor handling
characteristics
High solubility

45
MTA 1- Calcium Dentin bridge formation without necrosis
High shear bond strength
Residual monomer causes
cytotoxicity
Growth factors Formation of osteodentin & tubular dentin
Homogenous reparative dentin
Superior to calcium hydroxide
High concentration required
Less half life
Appropriate dose required to
prevent uncontrolled
obliteration of pulp
Odontogenic
ameloblast associated
proteins
Biocompatible
Accelerates reactionary dentin formation
Normal pulp tissue appearance
Invivo studies not conducted
Endo sequence root
repair material
Antibacterial property
Less cytotoxic than MTA, dycal
Bioactivity of cells were
decreased
Caster oil bean
cement
Good antibacterial property Less cytotoxic
Good mechanical properties
Facilitates tissue healing
Cost effective
Better sealing ability
Bioinert rather than bioactive
Clinical trials required
Thera cal Act as protectant
Strong physical properties
High calcium releasing activity
Whitish in colour- need thin
layer to prevent discoloration
of composite

LIMITATION OF DIRECT PULP CAPPING IN PRIMARY
TEETH
• Localization of infection & inflammation in primary teeth is poorer
than in permanent teeth. [McDonalds,1956]
• Incidence of reparative dentin formation in primary teeth is more
extensive than permanent Teeth. [Sayegh, 1968]
• Primary pulp contain high cellular content which might be
responsible for failures. Primary pulp responds more rapidly to
the effects of dentinal caries then the perm. Teeth. [Rayner &
Southam, 1979]
• Undifferentiated mesenchymal cells may differentiate into
osteoclasts in response to caries or pulp capping material which
could lead to internal resorption. [Kennedy,1985]
Casamassimo,fields,Pediatric dentistry,infancy through adolescence,5th edition 2013
46

• PULPOTOMY
• Definition:
Complete removal of coronal portion of the dental pulp, followed by
placement of a suitable dressing or medicament that will promote healing
and preserve vitality of tooth (Finn 1995).
Amputation of affected, infected coronal portion of the dental pulp preserving
the vitality and function of the remaining part of the radicular pulp (AAPD
1998).
47

INTRODUCTION
• Primary tooth pulp therapy is aimed at preserving the primary teeth
until normal exfoliation.
• Management of the cariously involved primary tooth where the
carious lesion approximates the pulp
• successful outcome depends on accurate diagnosis of the status of
the pulp prior to therapy.
• Preliminary we should focus on determining whether the primary
tooth pulp is normal, reversibly inflamed, irreversibly inflamed or
necrotic.
48Casamassimo,fields,Pediatric dentistry,infancy through adolescence,5th
edition 2013

• If it is determined to be vital or reversibly inflamed, the
vital pulp therapy techniques of pulpotomy or indirect
pulp treatment (IPT) are indicated.
• If the pulp is determined to be irreversibly inflamed or
necrotic, either a pulpectomy or extraction would be
appropriate.
49Casamassimo,fields,Pediatric dentistry,infancy through adolescence,5th
edition 2013

Objectives
 The radicular pulp should remain asymptomatic without adverse
clinical signs or symptoms such as sensitivity, pain, or swelling.
 There should be no postoperative radiographic evidence of pathologic
root resorption.
 The clinician should monitor the internal resorption, removing the
affected tooth if perforation causes loss of supportive bone and/or
clinical signs of infection and inflammation.
 There should be no harm to the succedaneous tooth.
50
Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY OF PEDIATRIC
DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014.

INDICATION
51
History
• Pain, if present not spontaneous or persists after removal of
the stimulus
McDonald, Avery, Dean, Dentistry for the Child and Adolescent, 8th edition,2007
Clinical Examination
• Cariously exposed primary teeth, when their retention is more
advantageous than extraction.
• Tooth which is restorable
• Vital tooth with healthy periodontium
• Hemorrhage from the amputation site is pale red & easy to control
• Absence of abscess and fistula
• On young permanent tooth with vital exposed pulp and
incompletely formed apices

Radiographically
• Nointer-radicular boneloss
• Nointer-radicular radiolucency
• Tooth with-2/3rd root length
52McDonald, Avery, Dean, Dentistry for the Child and Adolescent, 8th edition,2007

CONTRAINDICATION
53
History
• Persistent tooth ache.
Clinically
• Tenderness on percussion / mobility present.
• Large carious lesion with non-restorable
crown.
• Highly viscous, sluggish hemorrhage from
canal orifice which is uncontrollable.
• Tooth close to natural exfoliation.
Radiographically
• Root resorption more than 1/3rd of root length
• Evidence of internal resorption
• Presence of inter radicular bone loss
McDonald, Avery, Dean, Dentistry for the Child and Adolescent, 8th edition,2007

54
Pulpotomy
Vital
Devitalization
Single sitting
Fromocresol
Laser
Electrosurgery
Two stage
Glysi triopaste,
Paraform,
Easlick’s formaldeyde
Preservation
Glutraldehyde
Ferric Sulphate
Regeneration
BMP, MTA,
Enriched collagen,
Freezed dried bone,
Osteogenic protein
Non-vital
Beechwood cresol
Formocresol

A. DevitalizationPulpotomy
57
The first approach to pulpotomy treatment of primary teeth
was devitalisation.
Pulpotomy using formocresol was introduced by Buckley in
1904.
Since then various modifications have been tried and
advocated regarding the techniques of FC pulpotomy and the
concentrations.
John I. INGLE,DDS,MSD Ingle’s Endodontics 6th edition
1. FormocresolPulpotomy

58
History
1904 Formocresol was introduced to treat non-vital permanent teeth
by Buckley
1930 Sweet introduced the formocresol pulpotomy technique for primary
teeth.
Which involved five visits.
1955 Sweet reduced the number of visits over the years.
1962 Doyle et al used a two-visit procedure for 5 min pulpotomy
1960 A single visit procedure was advocated

• Buckley’sformulaofformocresol
• formaldehyde19%,
• Cresol35%,
• glycerin15%,
• WaterwithanapproximatepHof5.1.
59
John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition

Formocresol concentration
•It was concluded that 20% dilution causes the least
histologic damage and that a 1 minute application of
formocresol is adequate to produce the desired results.
•Garcia – Godoy (1984) advocated the use of 20%
dilution of formocresol for partial pulpotomies.
•showed a success rate 96%.
60
John I. INGLE,DDS,MSD Ingle’s Endodontics th Edition

Histologic investigation of the effect of formocresol
on the pulp
•Massler and Mansukhani suggested
•Immediately pulp becomes fibrous and
acidophillic.
•7 to 14 days : 3 zones appears
•A broad eosinophilic zone of fixation
•A broad pale-staining zone of atrophy
With poor cellular definition
• A zone of inflammation diffusing
apically into normal pulp tissue
61JOHN I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition

• Easily available medicament
• Stable at room temperature
• Long shelf life
• High clinical and
radiographic success
62
• It is a very caustic
medicament.
• Toxic if used in high dosage.
• Potential systemic
absorption and distribution
throughout the body.
• It has a mutagenic and
carcinogenic potential .
Advantages
DisadvantagesAdvantages Disadvantages

63
Title Author
Journal
L
O
E
Aim Materials and methodology Conclusion
Evaluation
of Four
Pulpotomy
Technique
s in
Primary
Molars: A
Randomiz
ed
Controlled
Trial
Ansari
G,
Pouya
Morovati
S,
Asgary
S.
Iranian
Endodon
tic
Journal
2018;13(
1): 7-12
3
a
to evaluate the
clinical and
radiographic
success rates
of calcium-
enriched mixture
(CEM) cement with
and without low
level laser therapy
(LLLT)
and compare them
to that of
formocresol (FC)
and ferric sulfate
(FS) in primary
molar
pulpotomies.
This randomized clinical
trial was conducted on a
total of 160 teeth selected
from 40 patients aged 3-9
years. Patients with at
least four primary
molars needing
pulpotomy, were included
in order to have each
tooth assigned randomly
in one of the four
following groups; FC, FS,
CEM, and LLLT/CEM.
Six- and twelve-month
follow-up periods were
conducted in order to
enable a clinical and
radiographic evaluation
of the treated teeth.
Collected data were
analyzed using Cochran
Q Test
Favorable
outcomes
of four treatment
techniques in
pulpotomy of
primary molar
teeth were
comparable. CEM
with/without LLLT
may be considered
as a safe and
successful
pulpotomy
treatment
modality compared
to current
conventional
methods.

2. Electrosurgical pulpotomy
 In 1982, Anderman described the electrosurgical pulpotomy in primary
teeth as a time-efficient method
 In 1983 Ruempling et al suggested cautery to fix radicular pulp tissue
after amputation.
 Routinely performed by Mack & Dean,1993,Non-pharmacotherapeutic
devitalization technique.
 Electrocautery carbonizes and heat denatures the pulp and bacterial
contamination.
64
John I. INGLE,DDS,MSD Ingle’s
Endodontics 6th Edition

65
1. the electrosurgery dental U-shaped electrode
should immediately placed 1-2 mm above the tissue.
2. The electrosurgery unit power should set at 40%.
3. The electrical arc should allowed to bridge the gap
to the first pulpal stump for 1s followed by a
cooldown period of 10-15 s.
This procedure was repeated up to three times at
each pulpal orifice.

• Itcanbeperformedmorequickly
• Nodrugsinvolvedthatmayproduce
undesirablesystemiceffects.
• Easeofuse
• Favorableresults.
66
• Heatleadstotissuedestruction
• Persistentinflammation
• Energycannotbeisolatedtosurface
• Rootresorption
• Pulpinflammation
Advantages Disadvantages

3.LaserPulpotomy
• Non-pharmacologichemostatictechnique.
• Advantages:
1. Quickandefficient
2. Self-limiting
3. Goodhemostasis
4. Goodvisibilityofthefield
5. Nosystemiceffects
6. Sterilizationatthesiteofapplication
68
Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy
Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 -
December, 2014

• Liu JF,2006 compared the effects of ND:YAG laser
pulpotomy with formocresol on human primry teeth.
• In the ND:YAG laser group,clinical success was
97%,and radiographic success was 94%.
• In formocresol pulpotomy the success rate was 85% and
78% respectively.
69
Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments:
Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014

70
Title Author
Journal
L
O
E
Aim Materials and
methodology
Results Conclusion
Laser
Pulpot
omy-
An
Effectiv
e
Alterna
tive to
Conve
ntional
Techni
ques: A
12
Months
Clinico
radiogr
aphic
Study.
G
Gupta,
V
Rana,
N
Srivas
tava,
P
Chand
na. Int
J Clin
Pediat
r Dent.
2015
Jan-
Apr;8(
1):18-
21
2
a
compare
the
clinical
and
radiogra
phic
success
rates for
ferric
sulfate
(FS),
electros
urgery
(ES) and
laser
pulpoto
my in
human
primary
molars.
n a randomized
clinical trial, 30
primary molars
indicated for
pulpotomy in children
aged 4 to 10 years
were treated using
either a FS (10
teeth), ES technique
(10 teeth) and laser
(10 teeth). Following
the pulpotomy, the
teeth were evaluated
for clinical and
radiographic success
at 3, 6, 9 and 12
months on the basis
of the presence of
pain, sinus, mobility,
internal and external
resorption, periapical
radiolucency,
calcification in the
canal and bone loss.
After 12 months of
follow-up, both
clinical and
radiographic
success rates
were 100% in the
laser group but
only 80% in both
ES and FS
groups. There
was statistically
significant
difference
between the
success rates of
three groups (p <
0.05).
•Laser pulpotomy
showed better
clinical as well as
radiographical results
than ES and FS
pulpotomy.
•Laser pulpotomy
was also found
superior in terms of
operating time,
patient cooperation,
ease of use and
pain.
•Although results of
the study showed the
failure rates for
electrosurgical
pulpotomy to be
equal to those for FS
pulpotomy,
electrosurgical
pulpotomy being a
nonpharmacological
technique considered
more favorable.

• In two stage devitalizing pulpotomy entire coronal and radicular
pulp tissue is fixed.
• Indications
1. Profuse or sluggish bleeding at amputation site
2. Difficult to control bleeding
3. Slight pus in the chamber but none at the amputation site
4. PDL Widening
5. spontaneous pain
6. Uncooperative patients.
7. Time factor 72

73
Procedure for 2 visit pulpotomy
1st visit
Anesthetize the
tooth
Isolate with rubber
dam
Cavity
preparation
Enlarge the
exposure with
round bur
Incorporate
paraformaldehyde
paste in to pallet
Place over the
exposure
Seal the tooth for
5-7 days
Formaldehyde
gas liberated from
paraformaldehyde
There will be
fixing of tissue

74
2nd visit
JOHN I. INGLE,DDS,MSD Ingle’s Endodontics 6th edition
Pulpotomy Is
carried out
under local
anesthesia
Remove the
old cotton
pallet and
Clean the
cavity with
saline & dry
with cotton
pallet
Pulp
chamber
filled with
antiseptic
paste & tooth
is restored
Final
restoration
with stainless
steel crown

Preservation:
•This approach involved medicaments and techniques
that provide minimal insult to the orifice tissue and
maintain the vitality and normal histologic appearance of
the entire radicular pulp.
•GLUTERALDEHYDE
•FERRIC SULPHATE
75
B. PRESERVATION PULPOTOMY
Franklin Garcia-Godoy. Clinical Evaluation of Gluteraldehyde
Pulpotomies in primary teeth. Acta de odontología pediátrica ·

1. Glutaraldehyde
 Glutaraldehyde for pulp fixation was proposed by
• S-Gravenmade in 1975.
 This di-aldehyde has a limited shelf life and a cross-
linking ability superior to that of formocresol.
 In recent years, glutaraldehyde has been proposed as
an alternative to formocresol based on its superior
fixative properties, self-limiting penetration, low
antigenicity, low toxicity and elimination of cresol.
76
INTRODUCTION
Franklin Garcia-Godoy. Clinical Evaluation of Gluteraldehyde Pulpotomies in primary
teeth. Acta de odontología pediátrica · January 1984

 formaldehyde reactions are reversible
 Glutaraldehyde has irreversible because it has better protein bonding
capacity
 Formaldehyde fixes tissue with a long reaction time and an excess of
solution
 glutaraldehyde fixes tissue instantaneously and an excess of solution is not
necessary.
 Formaldehyde is a small molecule and penetrates the periapical end easily.
 Glutaraldehyde being a large molecule does not penetrate into the periapical
tissue. Less pulpal irritation is seen because of less apical diffusion.
 Formocresol caused lysis of PMN and at high concentration but activation of
PMN adherence at low concentration.
 In contrast glutaraldehyde did not produce PMN lysis at high concentration,
nor did it cause activation of PMN adherence at low concentration.
77Franklin Garcia-Godoy. Clinical Evaluation of Gluteraldehyde Pulpotomies in primary
teeth. Acta de odontología pediátrica · January 1984

78
2. FERRIC SULPHATE
Larson 1988 Strong styptic,1st used in
military hospital in Bordeaux
,France 1857
prabhu et al 1997 It was proposed as a Pulpotomy
medicament for vital primary
teeth

79
 Ferric sulfate (Fe2[SO4]3) as a 15.5% solution (AstringedentTM,
Ultradent Products, Inc., Salt Lake City, UT), has been used
commonly as a coagulative and hemostatic retraction agent for
crown and bridge impressions and is slightly acidic.
 The mechanism of action of ferric sulfate is still debated, but
agglutination of blood proteins results from the reaction of blood with
both the ferric and sulfate ions.
 The agglutinated protein forms plugs to occlude the capillary orifices.
Raghavendra Havale, Rajesh T Anegundi, KR Indushekar, P Sudha. Clinical and
Radiographic Evaluation of Pulpotomies In Primary Molars With Formocresol,
Glutaraldehyde and Ferric Sulphate. Oral health and dental management. Vol. 12 - No. 1.
March 2013.

Advantages Of Ferric Sulfate Over
Formocresol
• According to Bimstein- replacement of Formocresol with ferric
sulfate in general anesthesia cases, where several pulpotomies
have to be done, can reduce systemic toxic effects caused by
Formocresol.
• Manipulation time of 15 seconds for Ferric sulfate is advantageous
when compared to 5 min for formocresol, with same success
rates.
• Systemic distribution of Ferric sulfate is unknown, because the clot
avoids
80
Glutaraldehyde and Ferric Sulphate. Oral health and dental management. Vol. 12 - No. 1.
March 2013.

Glutaraldehyde and Ferric Sulphate. Oral health and dental management. Vol. 12
- No. 1. March 2013.

82Akhlaghi N, Khademi A. Outcomes of vital pulp therapy in permanent teeth with different medicaments based

Regeneration:
•This approach includes pulpotomy agents that have cell-
inductive capacity to either replace lost cells or induces
existent cells to differentiate into hard tissue forming
elements.
83
C. REGENERATIVE PULPOTOMY
JOHN I. INGLE,DDS,MSD Ingle’s
Endodontics 6th edition

Examples of true cell- inductive agents include:
 Calcium hydroxide
 Mineral trioxide aggregate (MTA)
 Transforming growth factor- beta1 (TGF- b1) in the form
of bone morphogenetic protein
 Freeze Dried bone
 Enamel matrix derivative
84

1. Calcium Hydroxide
Single paste System –
Ex: Hypocal, Metapex .
• Available as
– Dry powdered Ca(OH)2.
– Single paste system.
– Two paste system.
– Root canal sealer.
• These solutions help as carriers / vehicles for easy placement of the material
• which can be used mixing it either with:
– Distilled water.
– Saline
– Glycerine.
– L.A solution without vasoconstrictor.
– Methyl cellulose.
85

• Two paste system – E.g.:
Alkaliner, Dycal, Basic.
• These system contains an
acid paste and a base
paste.
• This setting reaction based
on the reaction between
calcium and zinc ion and a
salicylate chelating agent
and is accelerated by the
presence of water.
DYCAL
Acid paste
Organic components – Methyl
salicylate ester.
Inorganic fillers
Titanium dioxide.
Calcium sulphate.
Calcium tungsten.
Alumina
Base paste
Inorganic components
Calcium hydroxide.
Zinc oxide.
Plasticizers
Ortho and Para 4-ethyl
toluene.
Sulphonamide
86

How Calcium Hydroxide Works
????
• Anti-microbial properties.
• Tissue Dissolution Properties.
• Biologic Properties.
– Pulp therapy procedures.
– Hard Tissue formation
87

Procedure
89
Grossman’s Endodontic Practice. 13th Edition.

90
Title Author
Journal
L
O
E
Aim Conclusion
Properties
and
applicatio
ns of
calcium
hydroxide
in
endodonti
cs and
dental
traumatol
ogy
Z.
Moham
madi &
P. M. H.
Dumme
r.
Internat
ional
Endodo
ntic
Journal,
44,
697–
730,
2011
5 is to review the
properties and
clinical applications
of calcium
hydroxide
in endodontics and
dental
traumatology
including
its antibacterial
activity, antifungal
activity, effect on
bacterial biofilms,
the synergism
between calcium
hydroxide and
other agents
Chemically, calcium hydroxide is
classified as a strong base with a high
pH (approximately 12.5–12.8). Its main
properties come from the ionic
dissociation of Ca2+ and OH ions and
their effect on vital tissues, generating
the induction of hard-tissue deposition
and being antibacterial. Although some
studies have confirmed its efficacy
against endodontic bacteria, other
studies have questioned it effectiveness.
their cytotoxicity appears to be milder
than for other groups of sealers.
Ca(OH)2 is a suitable material for pulp
capping and pulpotomy. MTA apical
barrier technique may replace it.
Ca(OH)2 has been successfully used to
manage perforations, horizontal root
fracture and root resorption.

2. Mineral Trioxide Aggregate
(MTA)
• INTRODUCED:1993 by Mahmoud Torabinejad (LOMA
LINDA UNIVERSITY)
• FDA APPROVAL -1998
• Available as
91

Macwan C, Deshpande A. Mineral trioxide aggregate (MTA) in dentistry: A review
of literature. Journal of Oral Research and Review Vol. 6, Issue 2, | July-December 2014
92

93Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review – Part III:
Clinical applications, drawbacks, and mechanism of action. J Endod 2010;36:400-13.
The MTA paste is obtained by mixing 3 parts of
powder with 1 part of water to obtain putty like
consistency (distilled water, local anesthesia,
normal saline).
Mixing can be done on paper or on a glass slab
using a plastic or metal spatula.
This mix is then placed in the desired location
and condensed lightly with a moistened cotton
pellet.
MTA has a pH of 10.2 immediately after mixing
and increases to 12.5 after 3 hours of setting
which is almost similar to calcium hydroxide.
The mixing time of MTA is crucial. If the mixing of
MTA is prolonged, it results in dehydration of the
mix. Sluyk et al in 1998 reported that the
mixing time should be less than 4 minutes.

Mechanism
• The exact mechanism of dentinal bridge formation when MTA is
used is not known completely and detailed research should be
carried out for understanding this mechanism.
• However, it was found that when MTA was used as a pulpotomy
agent it induces cytologic and functional changes within pulpal
cells, resulting in formation of fibrodentine and reparative dentin at
the surface of mechanically exposed dental pulp.
• When placed it causes proliferation, migration and differentiation
of odontoblast-like cells that produce a collagen matrix.
• This formed umineralized matrix is then mineralized by osteodentin
initially and then by tertiary dentin formation.
94
Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive
literature review – Part III: Clinical applications, drawbacks, and mechanism of
action. J Endod 2010;36:400-13.

• The high pH also extracts growth factors from adjacent dentin
thought to be responsible for promoting dentinal bridging.
• It is hypothesized that soluble components of MTA during and
after setting on the dentin interface may cause the release of
growth factors and other bioactive molecules, such as
transforming growth factor beta (TGF-b1).
• According to Tomson et al., the bioactive properties of MTA that
stimulate reparative bridge formation can be attributable to the
material providing a biocompatible noncytotoxic antibacterial
environment.
95
Koh ET, Pitt Ford TR, Torabinejad M, McDonald F. Mineral trioxide aggregate stimulates cytokine
production in human osteoblasts. J Bone Miner Res 1995;10S:S406.

96
Title Author
Journal
L
O
E
Aim Materials and methodology Results Conclusion
Mineral
trioxide
aggreg
ate and
formocr
esol
pulpoto
my of
primary
teeth: a
2-year
follow-
up
G.
Ansari
& M.
Ranjp
our.
Intern
ational
Endod
ontic
Journ
al, 43,
413–
418,
2010
3
b
To
compare
the
clinical
and
radiogra
phic
respons
e of
primary
teeth to
vital
pulpoto
my
using
mineral
trioxide
aggregat
e (MTA)
or
formocre
sol
(FC).
A group of 17 children aged
4–9
were selected from those
referred to the Paedodontic
Department at Shahid
Beheshti University, Dental
School. Cases with at least
two matching teeth were
selected (40 teeth), showing
signs of pulp involvement.
A pulpotomy procedure was
carried out in all cases
with FC in control teeth
whilst MTA was placed in
experimental teeth. Clinical
and radiographic
evaluations
were performed at 1-, 6-,
12- and 24-month
recall.
Internal
resorption was
seen significantly
more often in FC
cases
after 12 months
than MTA cases.
Overall
radiographic
appearance of
normal structures
at 24th month
was seen
in more than 95%
of the cases in
MTA and 90% in
the
FC-treated group
(P > 0.05).
Mineral
trioxide
aggregate for
pulp
treatment of
primary teeth
can be
considered a
replacement
for FC.

3. Biodentine
• Recently new calcium silicate material
• Available as..
– Biodentine (Septodont; Lancaster, PA)
Consist of Powder in a capsule and liquid in a pipette.
– Powder consist of dicalcium and tricalcium silicate
– Liquid is calcium chloride with admixture of modified
polycarboxylate
97

Mechanism Of Action
• After the application Mineralization occurs in the form of
osteodentine by expressing markers of odontoblasts &
increases TGF-Beta1 secretion from pulpal cells enabling
early mineralization.
• During the setting of the cement Calcium hydroxide is
formed.
• Due to its high pH, Calcium hydroxide causes irritation at the
area of exposure.
• Biodentine induces apposition of reactionary dentine by
odontoblast stimulation and reparative dentin by cell
differentiation.
• Because of its high alkality it has inhibitory effects on
microorganism.
98
Biodentine induces TGF-Beta 1 release from Human pulp cells and early dental pulp mineralization DEC
2011 1365-2591.2011.01995

99
Journal of Clinical and Diagnostic Research. 2017 Aug, Vol-11(8): ZG01-
ZG05

Journal of Clinical and Diagnostic Research. 2017 Aug, Vol-11(8): ZG01-
100

BioMed Research International Volume 2014, Article ID 160951, 10
pages
101

Ozlem M et. al,.A review of biodentine. BioMed Research International Volume 2014,
Article ID 160951, 10 pages
102

4. Growth factors: Bone Morphogenic
Protien
In 1938 Levander reported that there must be some stimulating
agent which originated from bone and possibly a substance which
was soluble in lymph tissue.
•Urist referred the bone inducing substance to “Bone Morphogenic
Proteins” which were originally identified by their presence in bone
inductive extracts of demineralized bone in 1965.
•Inducing substance i.e. Bone Morphorgenic Protein acting upon a
responding cell i.e. - undifferentiated mesenchymal cell to become
progenitor cell. Levander thus concluded that there is an extractable
substance from bone which is able to activate mesenchymal cells to
form tissue.
103
December, 2014

 Bone morphogenetic proteins
(BMPs) are a group of growth
factors also known as cytokines
and as metabologens.
 Originally discovered by their ability
to induce the formation of bone and
cartilage by promoting cell
proliferation and differentiation.
104
Kirker-Head CA1Recombinant bone morphogenetic proteins: novel substances
for enhancing bone healing.

• BMP belongs to super family transforming growth factor beta (TGF-
b).
• BMP-2, 4, and 7 plays a role in the differentiation of adult pulp cells
into odontoblasts during pulpal healing.
• Formation of more homogeneous reparative dentin.
• Superior to Ca(OH)2 in the mineralization inducing properties.
105

the application of BMP on exposed pulp is dissolved within two weeks
stimulates mitosis of the adjacent cells
differentiate into osteodentinoblasts
lay down osteodentin matrix
differentiation of odontoblasts were capable of inducing dentin
formation.
106
Kirker-Head CA1Recombinant bone morphogenetic proteins: novel substances for enhancing bone
healing.

5. Lyophilized Freeze Dried Platelet Derived Preparation
• Platelet derived growth factor ,insulin growth factor derived from
platelet have generated considerable intreast in the past.
• These compounds act as signaling proteins that could be directly
involved in the regulation of cell proliferation,migration and extra
cellular matrix production in the dental pulp.
• These proteins have been extensively used in oral and maxillofacial
reconstruction adjunctive procedures related to the placement of
osseo integrated implant in humans and periodontal regeneration.
• animal and human in-vivo and invitro studies have shown that these
proteins stimulates differentiated cell of the pulp to differentiate into
odontoblast to deposit a layer of dentin.
107

Damle & Kalaskan R et al compared efficiency of
lyophilized freeze dried platelet derived with calcium
hydroxide as pulpotomy agents in primary molars.
It was found that success rate of lyophilized freeze dried
platelet derived pulpotomy proved to be more efficient.
108

5. Emdogain (EMD)
• EMD is enamel matrix derivative secreted from Hertwig’s
epithelial root sheath during tooth development.
• It is an important regulator of enamel mineralization and plays an
important role during periodontal tissue formation.
• It stimulates the regeneration of acellular cementum, periodontal
ligaments, and alveolar bone.
109
Qureshi A, E. S, Nandakumar, Pratapkumar, Sambashivarao. Recent Advances in Pulp Capping Materials:
An Overview. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(1):316-321.
doi:10.7860/JCDR/2014/7719.3980.

• EMD contains BMP like molecules and BMP expressing cells. It
promote odontoblast differentiation and reparative dentin
formation
• It was reported that EMD suppresses the inflammatory cytokine
production by immunocytes and contains TGF-β like molecules. It
might create a favourable environment for promoting wound
healing in the injured pulp tissues .
• Nakamura Y et al., concluded that amount of hard tissue formed
in EMD treated teeth was more than twice that of the calcium
hydroxide treated control teeth
•Qureshi A, E. S, Nandakumar, Pratapkumar, Sambashivarao. Recent Advances in Pulp
Capping Materials: An Overview. Journal of Clinical and Diagnostic Research : JCDR.
2014;8(1):316-321. doi:10.7860/JCDR/2014/7719.3980.
110

Sodiumhypochlorite(NaOCl)
• Sodiumhypochlorite(NaOCl)hasbeensuccessfullyusedfordecadesin
endodontictherapyasanirrigant.
• Sincethe1950s,studieshaveverifiedthatNaOClisbiocompatible,
nonirritatingtoexposedpulpaltissueandaneffectivehemostaticagent.
• Hafezetal(2002)andothersdemonstratedthattheapplicationofNaOCl
selectivelydissolvesthesuperficialnecroticpulptissuewhileleavingthe
deeperhealthypulptissueunharmed
111
Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued
Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014

• Cox et al(2002) reported that hemostasis is best achieved with
NaOCl. reported similar success rate of NaOCl/RMGIC when
compared to FC/ZOE in their 3 month evaluation.
• Vargas et al. (2006) showed promising results from a pilot study
using 5% NaOCl as a primary molar pulpotomy agent.
• Histologically Roza et al (2012) noted mild inflammation and also
dentin bridge formation after 2 months following NaOCl pulpotomy
112
Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4
- December, 2014

115
Title Author
Journal
L
O
E
Aim Materials and
methodology
Results Conclusi
on
A
histopatho
logical
compariso
n of pulpal
response
to
formocres
ol and
sodium
hypochlori
te used as
pulpotomy
medicame
nts: In
primary
teeth – A
clinical
trial
Reddy
S, Red
dy V, T
Sneha,
Reddy
A, P
Niharik
a,Kum
ar J.
JISPP
D 2019
3b to evaluate
and compare
formocresol
(FC) and 5%
Sodium
hypochlorite
(NaOCl) as
pulpotomy
medicaments
and to assess
the
histological
features of
both
pulpotomy
medicaments
in primary
teeth
In the present study,
pulpotomies were
performed on 60
primary molars in 55
children aged 5–8
years. The teeth
were divided into
two groups NaOCl
and FC were placed
on the canal orifices,
respectively, and
crowns were
restored with
intermediate
restorative material
and glass ionomer
cement.
No
statistically
significant
difference
was found
between the
two groups
with respect
to
inflammatory
response,
soft-tissue
organization,
and dentin
bridge
formation
(P > 0.005)
Based on
the
results of
this study
Sodium
hypochlo
rite may
be a
suitable
medicam
ent for
conducti
ng
pulpotom
y in
primary
teeth.

6.Bioactiveglass
• Bioactive glass has been studied more than 30 years as a bone
substitute.
• It reacts with aqueous solution and form a carbonate apatite layer.
• BAGs considered as osteoconductive.
• BAGs are biocompatible, antibacterial and stimulate osteoblasts.
[Salako N, 2003]
116

• Some authors state odontoblast stimulation and subsequent
reparative dentin formation; however studies are ongoing to prove
exact mechanism of bridge formation.
• Animal study by Salako et al(2003), reported that BAG showed
localized areas of inflammation in the pulp especially in the mid root
portion and 4 week old samples showed comparative better results
where the inflammation was resolved and odontoblastic layer was
evident.
117

118
Title Author
Journal
L
O
E
Aim Methodology Conclusion
Compa
rison of
bioactiv
e glass,
mineral
trioxide
aggreg
ate,
ferric
sulfate,
and
formocr
esol as
pulpoto
my
agents
in rat
molar.
Salako
N,
Josep
b B,
Ritwik
P,
Salone
n R,
Jobn,
Junaid
T.
Dentil
!
Trau
matol
ogy
2003:
19:
314-
320
4 to evaluate
BAG as a
pulpotomy
agent and to
compare it
with three
commercially
available
pulpotomy
agents such
as
formocresol
(FC), ferric
sulfate (FS),
and mineral
trioxide
aggregate
(MTA).
Pulpotomies were
performed in 80
maxillary first molars of
Sprague Dawley rats,
and pulp stumps were
covered with BAG, FC,
FS, and MTA. Histologic
analysis was performed
at 2 weeks and then
at 4 weeks after
treatment. Experimental
samples were
compared with
contra-lateral normal
maxillary first molars.
Among the materials
tested, MTA
performed ideally as a
pulpotomy agent causing
dentine bridge
formation while
simultaneously
maintaining normal
pulpal histology.
It appeared that BAG
induced an inflammatory
response at 2 weeks
with resolution of
inflammation at 4 weeks.

7. Ankaferd Blood Stopper (ABS)
• Ankaferd Blood Stopper (ABS) is a herbal extract obtained from
5 different plants: Thymus vulgaris (mint), Glycyrrhiza glabra
(mulethi or jetthi muth), Vitis vinifera (grape vine), Alpinia
officinarum, and Urtica dioica.
• Each of these plants has some effect on the endothelium, blood
cells, angiogenesis, cellular proliferation, vascular dynamics
and also as cell mediators.
119
Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan Pulpotomy Medicaments:

• Goker et al(2008) explained following application of ABS, it forms
an encapsulated protein network that provides focal points for vital
erythrocyte aggregation.
• ABS- induced protein network formation with blood cells particularly
erythrocytes covers the primary and secondary haemostatic system
without disturbing individual coagulation factors.
• It is suggested that ABS may be used to control pulpal
haemorrhage following the mechanical exposure of pulps.
• StudiesonpulpotomywithABShaveshownsuccessraterangingfrom89%to100% (OdabaşME2011,
YamanE,2012).
120
Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan Pulpotomy Medicaments:

8.NanoHydroxyApatite
• NanoHydroxyApatitehasbeenintroducedforaugmentationproceduresinosseousdefects.
• NHA is biocompatible and non-irritating to pulp tissue.
121Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy
December, 2014

• Shayegan et al.(2010) following histological evaluation reported
that there was a significant difference between NHA and FC in terms
of pulp response.
• The results of the study show that NHA appears to be more
biocompatible and provokes only mild inflammatory reaction in pulp
tissue in both pulpotomy and direct pulp capping treatments.
122

9. Platelet Rich Plasma
• Platelet Rich Plasma was introduced by Marx in 1998 for
reconstruction of mandibular defects, and it represents a relatively
new biotechnology that is part of the growing interest in tissue
engineering and cellular therapy.
• Gibble and Ness in 1990 introduced fibrin glue, alternatively
referred to as fibrin sealant or fibrin gel, a biomaterial developed in
response to the necessity for improved haemostatic agents with
adhesive properties.
123

 Platelet Rich Plasma gel (PRP gel) is an autologous modification
of fibrin glue obtained from autologous blood used to deliver
growth factors in high concentrations.
 It is an autologous concentration of human platelets in a small
volume of plasma, mimics the coagulation cascade, leading to
formation of fibrin clot, which consolidates and adheres to
application site.
 Its biocompatible and biodegradable properties prevent tissue
necrosis, extensive fibrosis and promote healing.
124
Kevy SV, Jacobson MS. Comparison of methods for pointof care preparation of autologous platelet
gel. The Journal of Extra-corporeal Technology. 2004; 36: 28.

• Platelet rich plasma has been found to work via three mechanisms
a)Increase in local cell division (producing more cells): According to
Nathan E Carlson after the injury, platelets begin to stick to exposed
collagen proteins and release granules containing adenosine
diphosphate, serotonin and thromboxane, all of which contribute to
the hemostatic mechanism and the clotting cascade.
b)Inhibition of excess inflammation by decreasing early macrophage
proliferation.
c)Degranulation of the granules in platelets, which contain the
synthesized and prepackaged growth factors.
125
Kevy SV, Jacobson MS. Comparison of methods for pointof care preparation of autologous
platelet gel. The Journal of Extra-corporeal Technology. 2004; 36: 28.

10. Platelet rich fibrin
• Platelet rich fibrin (PRF) was first developed in France by
Choukroun et al. in 2001.
• Scientific rationale behind the use of platelet preparation lies in
the fact that PRF serve as a reservoir for continuous release of
growth factor which directs the process of reparative
dentinogenesis.[Smith AJ,2001]
• Huang et al.,[2012] investigated the effect of PRF on cultured
primary dental pulp cells and concluded that PRF can increase
dental pulp cell proliferation and differentiation.
126
Kevy SV, Jacobson MS. Comparison of methods for pointof care preparation of autologous platelet
gel. The Journal of Extra-corporeal Technology. 2004; 36: 28.

127
Journal of Indian Society of Pedodontics and preventive dentistry
2017

Partial Pulpotomy(Cvek’s Pulpotomy)
• Definition: It is the removal of only the outer layer of damaged and
hyperemic tissue in exposed pulps, is considered to be a procedure
staged between pulp capping and complete pulpotomy.
• Proposed by Mejare and Cvek in 1978
• The tooth following a partial pulpotomy will retain its natural color
and translucency in comparison to the coronal discoloration in many
teeth undergo after pulpectomy.
• preserves cell rich coronal pulp tissue.
128

• A small and recent pulpal exposure approximately 14 days in a non
carious tooth.
• A sufficient tooth structure is present to allow proper restoration.
• young permanent tooth with a wide- open apex and very thin root
dentin walls.
• During the procedure, an operative diagnosis should be made by
assessing the pulpal with regard to the bleeding from the amputation
site, including the color, viscosity, and ability of the tissue to achieve
hemostasis
129
Indications

Contraindications
• Very large Exposure
• More than 2 weeks have passes between injury and treatment time
• Inflammation beyond 2 to 3 mm of the exposure.
• Purulent drainage.
• History of prolonged pain.
• Necrotic debris in canal.
• Periapical radiolucency.
130

• Proper patient management should be achieved with or without
premedication.
• Local anesthesia and rubber dam placement should be administered
with the slit technique.
• A no. 330 tungsten bur is used to ampute the pulp close to the
exposure site to a depth of 2mm.
• Continuous rinsing of the amputed pulp with saline will assist in
achieving hemostasis without blood clot formation within 4 minutes
(if hemostasis is not achieved, all the coronal tissue should be
removed and a cervical pulpotomy should be performed).
131
Technique

132
Title Autho
r
Journa
l
L
O
E
Aim Materials and
methodology
Results Conclusion
Outcome
of Partial
Pulpoto
my in
Cariousl
y
Exposed
Posterior
Permane
nt Teeth:
A
Systema
tic
Review
and
Meta-
analysis
Ems
mari
F,
Ruiz
F,
Miro
Q,
Feijo
o N,
Dura
n F,
Gonz
alo J.
JOE
Vol.
No.
2019
1
a
to evaluate the
success
rate of partial
pulpotomy in
treating
permanent
posterior teeth
with carious
vital pulp
exposure. A
secondary aim
was to assess
the prognostic
factors using a
meta-
regression
An electronic search
was performed for
studies from January
1950 to November
2018 in the following
databases: PubMed,
ScienceDirect, and
Cochrane. All
searches were
performed following
the Preferred
Reporting Items for
Systematic Reviews
and Meta-
Analyses guidelines.
From the 218
studies identified
through the initial
search, 11 studies
qualified for the
final analysis (5
randomized clinical
trials and 6
retrospective
studies). The
results of the meta-
analysis indicate a
success rate of
98% , 96% and
92% after 6 months
and 1 and 2 years
of follow-up.
The available
data suggest
that a partial
pulpotomy
results in high
success rates
in treating
cariously
exposed
permanent
posterior
teeth up to 2
years

Journal of endodontics 2017 134

Non Vital Pulpotomy (Mortal Pulpotomy)
• Indications
• 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 cellulites
137

MEDICAMENTS USED:
Constituents of Beechwood cresol
• 2 Methoxy, 4 methyl phenol (Cresol): 13%
• Methoxyl phenol
• M-Methoxy phenol
• P-Methoxy phenol
• Unknown
:47%
:7%
:26%
:7%

Technique
Ist visit:
•The necrotic coronal pulp is first removed, as recommended in the vital
pulpotomy technique.
•The necrotic debris in the pulp chamber is then cleaned.
•If there is sufficient access to the radicular pulp canals then as much as
possible of the necrotic tissue is removed with a small excavator.
•A small cotton pellet dipped in beechwood cresol is then sealed into the
cavity with temporary zinc oxide eugenol cement.
139

• IInd visit:
• Usually 1-2 weeks later the dressing is removed, provided the signs
and symptoms of infection have cleared.
• The cavity is then restored
• If it appears that there is no resolution of the symptoms then the
beechwood cresol should be replaced for a further 1-2 weeks,
Other medicaments like formocresol, monochlorophenol (Arnold and
Rock, 1993) have been equally effective, at the second visit, after one
to two weeks an antiseptic paste that is placed over the radicular pulp
remnants before restoring the tooth replaces the antiseptic solution.
•Hobson (1970) reported a success rate of 66% after 3 years.
140

• Pulp capping is a procedure that maintains pulp vitality and function,
promotes healing/repair, prevents breakdown of peri radicular
supporting tissues, and promotes formation of secondary dentin
• Pulpotomy therapy for the primary dentition has developed a long
three lines: devitalization, preservation, and regeneration.
• Preservation, the retention of maximum vital tissue with no induction
of reparative dentin, is exemplified by glutaraldehyde and ferric
sulfate treatment.
• Regeneration, the stimulation of a dentin bridge, has long been
associated with calcium hydroxide.
141

Bibliography
• John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition.
• Cohen M, Burns RC. Pathways of Pulp. 9th ed. St. Louis: Mosby Inc.; 2002.
• Mcdonald RE, Avery DR, Dean JA. Dentistry for the Child and Adolescent. 8th ed.
2004: Mosby; Elsevier. p. 390-412.
• Grossman’s Endodontic Practice. 13th Edition.
• Textbook of Pediatric Dentistry by Nikhil Marwah. 3rd edition.
• Policy on Acute Pediatric Dental Pain Management. AMERICAN ACADEMY OF
PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2017
• Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY
OF PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014.
• Parisay I, Ghoddusi J, Forghani M. A Review on Vital Pulp Therapy in Primary Teeth.
Iranian Endodontic Journal 2015;10(1):6-15.
• Mohammadi Z, Dummer M H. Properties and applications of calcium hydroxide in
• endodontics and dental traumatology. International Endodontic Journal, 44, 697–730,
2011.
• Tandon S,Textbook of pedodontics,3rd edition,2009
142

143
• Franklin Garcia-Godoy. Clinical Evaluation of Gluteraldehyde Pulpotomies
in primary teeth. Acta de odontología pediátrica · January 1984.
• Raghavendra Havale, Rajesh T Anegundi, KR Indushekar, P Sudha. Clinical
and Radiographic Evaluation of Pulpotomies In Primary Molars With
Formocresol, Glutaraldehyde and Ferric Sulphate. Oral health and dental
management. Vol. 12 - No. 1. March 2013.
• Macwan C, Deshpande A. Mineral trioxide aggregate (MTA) in dentistry: A
review of literature. Journal of Oral Research and Review Vol. 6, Issue 2, |
July-December 2014.
• Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan
PPulpotomy Medicaments: Continued Search for New Alternatives- A
Review, OHDM - Vol. 13 - No. 4 - December, 2014
• Kevy SV, Jacobson MS. Comparison of methods for pointof care
preparation of autologous platelet gel. The Journal of Extra-corporeal
Technology. 2004; 36: 28.
• Qureshi A, E. S, Nandakumar, Pratapkumar, Sambashivarao. Recent
Advances in Pulp Capping Materials: An Overview. Journal of Clinical and
Diagnostic Research : JCDR. 2014;8(1):316-321.
doi:10.7860/JCDR/2014/7719.3980.

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