Finn 1995:

PULPOTOMY AND

PULPECTOMY

PULPOTOMY

Finn 1995:

• The complete removal of the coronal portion of the dental pulp, followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth.

Objective:

• Removal of inflamed and infected coronal pulp at the site of exposure. Thus preserving the vitality of the radicular pulp and allowing it to heal.

A. Pulpotomy can be classified according to treatment objectives (Don M. Ranly 1994^).

1. Devitalization pulpotomy (Mummification, cauterization) Single sitting : Formocresol

Two stage : Gysi Triopaste

Easlick’s Formaldehyde Paraform devitalizing paste

2. Preservation (minimum devitalization, non inductive) – Gluteraldehyde

– Ferric sulfate

Classification:

3. Regeneration (Inductive & Reparative) – Calcium hydroxide

– Bone morphogenic protein B. Depending upon the size of exposure

• Partial pulpotomy (shallow, low level or Cvek’s pulpotomy)

• Cervical pulpotomy (deep, high level, total or conventional pulpotomy) C. Classified depending upon the number of visits

• Single visit pulpotomy

•Multiple visit pulpotomy

INDICATIONS

• Pain if present is neither persistent nor spontaneous

• The tooth is restorable

• The tooth possesses at least 2/3^rd of its root length

• There is no evidence of internal root resorption

• There is no inter radicular bone loss

• No abscess or fistulae

• The hemorrhage from amputed site is pale red & easy to control.

CONTRAINDICATIONS

• Spontaneous pain

• Tenderness to percussion

• Swelling & fistula

• Pus or serous exudate at the exposure site

• Pathologic mobility

• Uncontrollable hemorrhage from the amputated pulp stumps

• Pathological external root resorption

• Periapical or interradicular radiolucency

• Internal root resorption

• Pulp calcifications

• Tooth close to natural exfoliation.

• Formocresol ( Buckley’s formula )

• Formocresol is a solution of -19% formaldehyde

- 35% cresol in a vehicle of -15% glycerin &

-water.

• The glycerine is added to prevent polymerization of formocresol to Para formaldehyde . The presence of Para formaldehyde causes clouding of the solution.

Anesthetize the tooth

Isolate tooth with rubber dam

Remove caries and determine site of pulp exposure

Remove roof of pulp chamber

PROCEDURE

Remove coronal pulp with a large (discoid spoon) excavator or a large round bur

Irrigate pulp chamber with saline and then dry with a sterile cotton pellet.

Using cotton pellet apply formocresol on pulp stumps for 4-5 minutes

Remove formocresol pledget and check that the haemorrhage has stopped

Fill pulp chamber with thick paste of ZOE

Recall after one week and restore with a permanent restoration if patient is asymptomatic Restore the tooth with a

stainless steel crown

Take a postoperative radiograph

HISTOLOGICAL CHANGES:

Immediately: Pulp becomes fibrous and acidophilic.

• 7 – 14 days : Three zones appear:

1. A broad eosinophillic zone of fixation

2. A broad pale staining zone of atrophy with poor cellular definition

3. A zone of inflammation extending apically into normal pulp tissue

• 1 Year: Progressive apical movement of these zones with only acidophilic zone left at the end of 1 year.

DEVITALIZATION (Two sitting)

• This is two–stage procedure involving the use of Para

formaldehyde to fix the entire coronal and radicular pulp tissue

•

Indications:

• Sluggish bleeding at the amputation site that is difficult to control

• Pus in the chamber, but none at the amputation site

• Thickening of the PDL.

• History of pain Contradictions:

• Non-restorable tooth

• Tooth with necrotic pulp

MATERIAL USED:

Gysi trio paste:

• Tricresol

• Cresol

• Glycerine

• Para formaldehyde

• Z0E

Easlick’s Para formaldehyde paste:

• Para formaldehyde

• Procaine base

• Powdered asbestos

• Petroleum jelly

Para form devitalizing paste:

• Para formaldehyde

• Lignocaine

• Propylene glycol

• Carbowax

• Carmine to colour

Isolation with rubber dam

Preparation of the cavity

Deep caries excavated

When pulp exposure is encountered during excavation of deep caries after ensuring that the exposed site is free of debris, enlarge the exposure with round bur

Place paraformaldehyde paste over exposure

Seal the tooth for 1-2 weeks.

PROCEDURE:

1^st visit

Remove the old cotton pellet.

Clean the cavity with saline and dry with cotton pellet.

Pulp chamber filled with ZOE paste and tooth is restored.

2^nd visit

B. PRESERVATION

• The medicaments used in this induce minimal insult to the tissue. They are not capable of initiating inductive process but they help to conserve vitality of the radicular pulp

• The chemicals are:

Glutaraldehyde 2%-5%

Ferric sulphate

Glutaraldehyde Pulpotomy

• It was first suggested by S. Gravenmade

• It was first introduced by Kopel in 1979

ZONES FORMED ARE:

• Initial zone of

fixation that does not migrate apically.

• Tissue adjoining the fixed zone has

cellular details found in normal pulp

tissues.

ADVANTAGES

• It is bi-functional reagent, which allows it to form strong intra and intermolecular protein bonds leading to superior fixation by cross linkage.

• It is excellent antimicrobial ( conc of 3.125%).

• Causes less necrosis of the pulpal tissue.

• Causes less dystrophic calcification in pulp canals.

• Less toxicity

• Less systemic distribution

FERRIC SULPHATE:

• Is a nonaldehyde haemostatic compound.

Comparison with formocresol

• Ferric sulphate and formocresol produce equivalent outcomes.

• Fixative properties of formocresol produced the barrier to some irritating

property of eugenol , while clotting characteristics of ferric sulphate were not as good at producing barrier, leading to pulpal inflammation and resorption.

C. REGENERATION

• An ideal pulpotomy should leave radicular pulp vital, healthy and enclosed in odontoblastic lined chamber. The agents used in this are;

• Ca (OH)₂

• Bone morphogenic protein(BMP)

• MTA

• Enriched collagen

• Freezed dried bone

• Osteogenic protein

LASER PULPOTOMY

• It is a non pharmacological approach

• After complete removal of pulp from pulp chamber, exposure of diode laser or Nd : YAG laser was done for haemostasis.

• Then IRM paste was placed over the pulp stumps and restoration

was done.

CVEK’S PULPOTOMY

• This was proposed by Mejare and Cvek

• partial pulpotomy

Indication:

• In young permanent teeth where the pulp is exposed by mechanical or bacterial means

• The root closure is not complete.

PROCEDURE:

• local anaesthesia &Application of rubber dam

↓

• All carious material is removed & starting from the exposure 1-2 mm of the pulp tissue is removed with high speed rotating spherical diamond bur with ample water flow to give least trauma to pulp

↓

• Rinse gently with sterile saline & place cotton pellet



• After arrest of the haemorrhage, 1mm thick layer of Ca (OH)₂is applied to the exposed pulp, ensuring that there is no blood clot.

↓

• The cavity is then sealed with temporary restorative material.

↓

• The tooth should remain symptom free at recall (6-8 wks) and radiograph should show formation of a secondary dentine bridge → Then permanent restoration is done.

MORTAL PULPOTOMY (NON-VITAL PULPOTOMY)

• A non-vital tooth should be treated by pulpectomy and root canal filling.

• However, pulpectomy of primary molar is difficult due to non-negotiable root canals and also due to limited patient's cooperation.

• Hence, a two stage pulpotomy technique is advocated.

Selection Criteria:

• History of spontaneous pain.

• Swelling, redness or soreness of mucosa.

• Tooth mobility.

• Tenderness to percussion.

• Radiographic evidence of pathological root resorption or periradicular bone destruction.

• Pulp at the exposed site does not bleed.

FIRST APPOINTMENT

Necrotic coronal pulp is removed.

The pulp chamber is irrigated with saline and dried with cotton pellet; infected

radicular pulp is treated with a strong antiseptic solution such as beechwood cresol.

Dip the pellet in beechwood cresol and remove the excess by damping it on sterile cotton and place it in the pulp chamber over the radicular pulp.

Seal the cavity with temporary cement for one or two weeks.

SECOND APPOINTMENT

If there are no symptoms the pulp chamber can be filled with a antiseptic paste.

While filling the pulp chamber the antiseptic paste can be firmly pushed into the root canals with cotton pellets.

The tooth can be restored with stainless steel crown.

NON-VITAL PULP THERAPY

PULPECTOMY

• Definition-

• The complete removal of the necrotic pulp from the root canals of primary teeth and filling them with an inert resorbable material so as to maintain the tooth in the dental arch.

(Mathewson)

• Pulpectomy as removal of all pulpal tissue from the coronal and radicular portions of the tooth.

(FINN)

INDICATIONS:

• Primary teeth with pulpal inflammation extending beyond the coronal pulp but with roots and alveolar bone free of pathologic resorption

• Primary teeth with necrotic pulps, minimum root resorption, and minimum bony destruction in the bifurcation area

• Pulpless primary teeth with sinus tracts

• Pulpless primary teeth without permanent successors

CONTRAINDICATIONS:

• A non-restorable crown

• Excessive internal resorption

• Extensive pulp floor opening into the bifurcation

• Young patients with systemic illness such as congenital or rheumatic heart disease and leukemia

• Primary teeth with underlying dentigerous or follicular cysts.

Procedure

Take pre operative photograph and radiograph.

Anesthetize the tooth and isolate with rubber dam.

Remove caries and identify exposure site.

Remove roof of pulp chamber and identify opening of root canals.

Take a diagnostic radiograph with files in the root canals to check working length

Remove pulp tissues using Endodontic files and irrigate canals with saline.

• File –not more than size 30

Dry root canals with paper points and place a pledget of formocresol in pulp chamber for 4 min.

Select a spiral root canal filler of appropriate size.

Mix ZnO and eugenol as a paste and spin it into root canals using spiral root canal filler.

Fill pulp chamber with ZOE cement.

Place Permanent Restoration

Restore tooth with stainless steel crown.

Take a post operative radiograph

Difference between deciduous pulpectomy & Conventional endodontic procedure in permanent teeth

• Morphologic appearances of deciduous root canals are very fine, filamentous connection of the pulp system make complete debridement of the root canal difficult.

• Deciduous root undergo physiologic resorption prior to the exfoliation of the tooth. This makes us to use resorbable filling material, usually a zinc oxide and eugenol paste, rather than gutta percha or silver points, which are used in

permanent endodontic procedures.

• filling and shaping of primary root canals must be performed short of the radiographic apex and to minimize the chances of mechanical perforation.

OBTURATING MATERIALS

• The material should resorb as the roots of primary teeth resorbs.

• Should not irritate periapical tissues.

• Should be able to adequately disinfect and seal the canals.

• Should be non toxic.

• If surplus material has been filled in periapical area then it should be easily resorbed.

• Should have proper consistency on mixing so that it can be adequately pushed into the canal.

• It should not discolour the tooth.

• Should be radiopaque.

• Should be harmless to the adjacent tooth bud.

IDEAL REQUIREMENTS :

ZINC OXIDE EUGENOL

• Sweet (1930) - first described the use of ZOE as root canal filling material..

• It is most commonly used filling material for primary teeth.

• Underfilling relatively common finding when thick mix of ZOE employed.

Irritation and cytotoxic effect on periapical tissues.

Reduced rate of resorption than that of tooth root.

Disadvantages -

Vitapex/Metapex

When it extruded into furcal and Periapical areas, can either diffuse away or be resorbed. Bone regeneration has been clinically and histologically

documented after using vitapex.

Vitapex/Metapex- Calcium Hydroxide + Iodoform + oil additives

COMPOSITION OF OTHER ROOT CANAL MATERIALS FOR PRIMARY TEETH

Walkhoff paste KRI paste Maisto paste Endoflas

•Parachlorophe nol

• Iodoform • Zinc Oxide • Calcium hydroxide

• Camphor • Camphor • Iodoform • Iodoform

• Menthol •Parachlorophenol • Thymol • Barium sulfate

• Menthol •Chlorophenol Camphor

• Zinc oxide eugenol

• Lanolin

References

• Textbook of Pediatric Dentistry- Nikhil Marwah.

• Textbook of pediatric dentistry- Shobha Tandon.

• Pulp Therapy for Primary and Immature

Permanent Teeth (2017). The Reference

Manual of Pediatric Dentistry.

THANK YOU