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PEDIATRIC

ENDODONTICS
PULPOTOMY

Surgical removal of entire coronal pulp presumed to be


partially or totally inflamed & quite possibly infected,
leaving intact the vital radicular pulp within the canals

A germicidal material is placed over the remaining vital


radicular pulp stumps at their point of communication
with the floor of the coronal pulp chamber

Most widely used & the most successful technique


RATIONALE

To promote healing & retention of vital


radicular pulp

Dentin bridging may occur as a treatment


outcome - depending upon:
o the type of medicament used
o its concentration,
o time of tissue contact
INDICATIONS:

1. Cariously exposed primary teeth when their retention is more


advantageous than extraction

2. Demonstrating clinical and R/g signs of:


- Radicular pulp vitality
- Absence of pathologic change
- Restorability
- 2/3rd root remaining
3. Young permanent teeth with cariously exposed pulp

.
CONTRAINDICATIONS:

1. Root resorption exceeds >1/3rd of the root length


2. Tooth crown is nonrestorable
3. Highly viscous/sluggish/absent hemorrhage at orifice
4. Marked tenderness to percussion
5. Mobility with locally aggravated gingivitis associated
with partial or total radicular pulp necrosis
6. Radiolucency in furcal or periradicular area
7. Persistent toothaches and coronal pus
PARTIAL PULPOTOMY
- CRITERIAS (Mass et al.1995)
No pain/ recent pain of short duration

No swelling, mobility, reaction to percussion

No internal/external resorption, PDL changes, R/G ab.

Pulp exposure 1-2 mm, bleeding stops < 1-2 min.

Inflammation/ infection - superficial only


PULPOTOMY contd

TREATMENT APPROACHES:

THREE CATEGORIES
(varying with rationale & various medicaments)

1. DEVITALIZATION
2. PRESERVATION
3. REGENERATION
1. DEVITALIZATION:

To mummify the radicular pulp tissue

(Chemically treated pulp tissue that is inert, sterilized,


metabolically suppressed, and incapable of autolysis)

Original two-sitting formocresol pulpotomy

5min. formocresol and 1:5 diluted formocresol -


partial devitalization
2. PRESERVATION:
Medicaments & techniques- minimal insult
Maintain the vitality and normal histological
appearance of the entire radicular pulp

Pharmacotherapeutic Non-pharmacotherapeutic
- Corticosteroids - Electrosurgical
- Glutaraldehyde - Laser
- Ferric sulphate
3. REGENERATION:

Pulpotomy agents with cell inductive capacity to either:


replace lost cells induce for differentiation

True Cell Inductive Agents:

- Transforming growth factor- (TGF- ): Bone


morphogenetic proteins (BMPs)

- Freeze dried bone

- Mineral trioxide aggregate (MTA)


BUCKLEYS FORMOCRESOL

- 35% tricresol

- 19% formaldehyde

- 15% glycerine and water solution


DILUTION OF FORMOCRESOL

1/5th strength dilution:


- Mix 3 parts of glycerine with 1 part of distilled water
- Add this 4 parts to 1 part of concentrated formocresol

Histology & clinical success comparable to full strength

Neither produces ideal histology

Long-term clinical success of 1:5 - still questioned


PULPAL REACTIONS TO
FORMOCRESOL:
No dentin bridging

Fixation of tissue directly under the medicament

Effect varied with the length of time of contact:


- a 5 min. application:
surface fixation vital pulpotomy
- application sealed in for 3 days:
calcific degeneration nonvital pulpotomy
HISTOLOGY- FORMOCRESOL

- Zone of fixation:
fixation A broad eosinophilic zone

- Zone of atrophy:
atrophy A broad pale-staining zone with
poor cellular definition

- Zone of inflammation:
inflammation Diffusing apically into normal
pulp tissue
FIXATION

Preserves cellular detail

Inhibits autolytic changes and bacterial growth

Coagulates protoplasm rendering it insoluble

Increases affinity for particular stains


SUCCESS RATES IN LITERATURE:

62-100% depending on study and criteria used

Clinical > Radiographic > Histological

Formocresol Pulpotomies:
may be empirical clinical success, but histologically
they are failures to one degree or another
F PULPOTOMY TECH. IN 1O TEETH

I. ONE APPOINTMENT PULPOTOMY:

INDICATIONS:
Restorable teeth with inflammation confined to
coronal portion of the pulp

Only vital, healthy pulp tissue should remain in the


root canal after coronal amputation
CONTRAINDICATIONS:

Teeth with a history of spontaneous pain


Profuse hemorrhage on entering the pulp chamber
Pathologic root resorption
Roots with 2/3rd resorbed/ internal resorption
Inter-radicular bone loss
Presence of a fistula
Presence of pus in the chamber
PROCEDURE:

1. Anesthetize the tooth & tissue


2. Isolate with a rubber dam
3. Excavate all caries
4. Remove the dentin roof of pulp chamber
5. Remove all coronal pulp tissue
6. Achieve hemostasis with cotton pellet
7. Apply cotton pellet with diluted formocresol on pulp
for 3-5 min.
8. Place a ZoE cement base
9. Restore the tooth with a stainless steel crown
II. TWO APPOINTMENT
PULPOTOMY:
INDICATIONS:
Evidence of sluggish or profuse bleeding at the site
Difficult-to-control bleeding
Slight purulence at the chamber, but none at the amputation site
Thickening of the PDL
H/O spontaneous pain without other contraindications
Shorter appointments needed for patient management
CONTRAINDICATIONS:

Nonrestorable teeth

Soon to be exfoliated teeth

Necrotic teeth
PROCEDURE:

1. Same as for one appointment procedure till step 6


(hemostasis)

2. Cotton pellet moistened with diluted formocresol is


sealed into the pulp chamber for 5 to 7 days

3. At 2nd visit, temporary filling and cotton pellet are


removed and chamber is irrigated well and dried

4. ZoE cement base placed & stainless steel crown given


CONCERNS ABOUT FORMOCRESOL

1. Local toxicity

2. Systemic toxicity

3. Mutagenicity and Carcinogenicity


GLUTARALDEHYDE

Glutaraldehyde - More desirable than Formocresol

Superior fixation by cross linkage

Limited diffusibility - less pulpal irritation

Excellent microbial agent

Less dystrophic calcification

Less cytotoxic and antigenic


GLUTARALDEHYDE- HISTOLOGY

Initial
zone of fixation that didnt progress
apically

Tissue adjoining the fixed zone and down to


the apex
- cellular detail of normal pulp
- presumably vital
GLUTARALDEHYDE contd

Cold,buffered, 2% Glutaraldehyde
most stable

Higher success rates (96-100%)


ALTERNATIVE PULPOTOMY
AGENTS

FERRIC SULFATE

CELL-INDUCTIVE AGENTS:
- Mineral trioxide aggregate
- Calcium phosphate cement
- Calcium phosphate ceramics
- Hydroxyapatite
- Bone morphogenic proteins
- Freeze-dried bone
FERRIC SULPHATE

FS forms ferric ion-protein complex; occludes


capillaries at the amputation site mechanically

Must assume healthy pulp


NON-PHARMACOTHERAPEUTIC
PULPOTOMY TECH. - Controlled Energy

BASIC PRINCIPLES:
Amputate infected coronal pulp

Treat remaining radicular pulp by controlled energy

Neutralize residual infectious process

Avoid dystrophic pulpal changes

Avoid breakdown of periradicular supporting tissues


Electrosurgical Pulpotomy

ADVANTAGES:
Quick and efficient
Good homeostasis
Good visibility of the field
No systemic effects
Sterilization at the site of
application
Electrosurgical Pulpotomy

DISADVANTAGES:
Heat leads to tissue destruction

Persistent inflammation

Energy cannot be isolated to surface

Pulp inflammation
LASERS

Nd:YAG (neodymium: yttrium-aluminum-garnet)

Effectiveness equivocal to conventional


pharmacotherapeutic techniques

Successful outcome following:


Lower power settings
Shorter application