PULPOTOMY PROCEDURES IN PRIMARY DENTITION

index
A. B. C. D. E. F. G. H. Definition Classification Technique Formocresol pulpotomy Ca(OH)2 pulpotomy Other procedures Summary References

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

classification
Pulpotomy Partial pulpotomy complete pulpotomy formocresol pulpotomy

calcium hydroxide pulpotomy

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

Vital pulpotomy technique

1. Glutaraldehyde 2. Ferric sulphate

Devitalization Preservation

Single sitting
Formocresol Electrosurgery Laser

Two stage

1. Bone morphogenetic protein 2. Dentin chips

Regeneration

Gysi triopaste Easlicks formaldehyde Paraform devitalising pastePreservation

Formocresol pulpotomy
Formocresol was introduced in 1904 by Buckley, who contended that equal parts of formalin and tricresol would react chemically with the intermediate and end products of pulp inflammation to form a new, colorless, and non-infective compound of a harmless nature.

Buckleys formula
formocresol, consists of tricresol, 19% aqueous formaldehyde, glycerine, and water.

indications
1. 2. 3. 4. 5. 6. 7. Carious / mechanical exposure in vital asymptomatic tooth Tooth free of radicular pulpitis Presence of atleast 2/3rd root length Absence of abscess or fistula. Absence of inter radicular bone loss Absence of internal root resorption Permanent posterior teeth for the expedient treatment of pulpalgia. (it relieves pain in emergency as formocresol fixes the contiguous pulp left in the root canal.)

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

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

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

One-Appointment Pulpotomy.
Indications :only on those restorable teeth in which it has been determined that inflammation is confined to the coronal portion of the pulp.

Contraindications : Teeth with a history of spontaneous pain Profuse haemorrhage Pathologic or internal root resorption Inter radicular bone loss Presence of fistulas or pus in the chamber

PROCEDURE
Anesthetize the tooth and tissue.

Isolate the tooth with rubber dam

Remove caries & determine site of pulp exposure

Remove roof of pulp chamber

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

Apply formocresol on the pledge of cotton wool for 4 minute

Remove formocresol pledget after 4 min. & check that haemorrhage has stopped

Fill pulp chamber with cement

Restore the tooth with stainless steel crown

Take a post operative photograph

Two-Appointment Pulpotomy.
Indications
(1) Evidence of sluggish or profuse bleeding at the amputation site (2) Difficult-to-control bleeding (3) Slight purulence in the chamber but none at the amputation site (4) Thickening of the periodontal ligament (5) A history of spontaneous pain without other contraindications.

Contraindications.
(1) Nonrestorable (2) Soon To Be Exfoliated (3) Necrotic.

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

Partial pulpotomy (pulp curretage )

It is removal of coronal pulp tissue up to the level of healthy pulp. This process is also known as partial pulpotomy.

INDICATIONS : -when zones of inflammation has extended more than 2 mm. in an apical direction but has not reached root pulp. Eg. A traumatic exposure (a few days post injury in a large young pulp)

TECHNIQUE
1. 2. 3. Area is anaesthetised and isolated A 2 mm. deep cavity is prepared into pulp using sterile diamond bur and copius water coolent Excess blood is removed by saline & small cotton pelletes Calcium hydroxide is placed onto cavity Sealed with ZOE reinforced IRM restoration. IT IS RARELY SUCESSFUL AND HENCE HAS NO CLINICAL SIGNIFICANT.

4. 5.

REASONS FOR FAILURE

Pulp is highly vascular so, even with slightest infection in any corner of pulp , the whole of it gets infected very quickly.

Its practically impossible to remove one part of coronal pulp without disturbing the other parts of it in pulp chamber.

DEVITALIZATION PULPOTOMY
It is two stage procedure involving the use of paraformaldehyde to fix the entire coronal & radicular pulp tissue.

The medicament used have a devitalizing, mummifying, & bactericidal action.

TECHNIQUE
First appointment :-

Same as formocresol pulpotomy but place the paraformaldehyde paste in cotton pellete over the exposure & seal the tooth for 1 to 2 weeks. Formaldehyde gas liberates from the paraformaldehyde permeates through the coronal and radicular pulp, fixing the tissue.
Second appointment :-

pulpotomy is carried out with the help of local anaesthesia

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

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

Glutaraldehyde
by kopel (1979 )
1. 2. 3. 4. 5. Advantages over formocresol Superior fixative property Self limiting penetration Low antigenicity Low toxicity Elimination of cresol 2-5 % concentration

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

references
Restorative technique for paediatric dentistry - Ms DUGGAL, MEJ CURZON, SA FAYLE, KJ TOUMBA, AJ ROBERTSON Endodontic Fifth Edition - JOHN I. INGLE, LEIF K. BAKLAND Text Book Of Pedodontics - SHOBHA TANDON

Clinical Pedodontics - FINN

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