PEDIATRIC ENDODONTICS

Fo

iz ation
PULPOTOMY rm
oc
re
so
ita l l
Dev

Gl
ut
ar
r va tion al
de
e
Pres hy
de

tion M
er a TA
en
Reg

Presented By: Dr.

Rajeev Kumar Singh
 DEFINITION Finn

Pulpotomy can be defined as the complete removal of coronal portion of the

dental pulp, followed by placement of suitable dressing or medicament that
will promote healing & preserve vitality of the tooth
 Pulpotomy/Pulpectomy

PULP
+
OTOMY  to make an incision or cut into

PULP
+
ECTOMY  surgical excision of a part
3
4
Removal of inflamed & infected coronal pulp thus
preserving the vitality of the radicular pulp and
allowing it to heal

Maintain the tooth in the dental arch

5
6
 Cariously exposed primary teeth, when their retention is more
advantageous than extraction and replacement with a space maintainer.

 clinical and radiographic signs of radicular pulp vitality

 Pain, if present not spontaneous nor persists after removal of the stimulus

 Tooth which is restorable

 Tooth with at least 2/3rd root length

 Haemorrhage from the amputation site is bright red & easy to control

7
 root resorption exceeds more than one-third of the root length
 the tooth crown is non-restorable
 highly viscous, sluggish, or absent hemorrhage is observed at the
radicular canal orifices
 marked tenderness to percussion
 mobility with locally aggravated gingivitis associated with partial or
 total radicular pulp necrosis exists
 radiolucency exists in the furcal or periradicular areas
 Persistent toothaches and coronal pus

8
 Indications ??

Contra-indications ??

9
 Classification

Vital Non-vital

Devitalization Regeneration Preservation

One visit Two visits

According to removal of coronal tissue

Partial Complete
 Devitalization Pulpotomy
(mummification, cauterization)

One visit Two visits

Formocresol Gysi Triopaste

Electro surgery Easlick’s Formaldehyde
Paraform devitalizing paste
Laser

Destroy or mummify the vital tissues 11

 Preservation Pulpotomy
(minimal devitalization, non-inductive )

Zinc Oxide Eugenol

Glutaraldehyde

Ferric sulfate

Maintain maximum vital tissue without induction of reparative 12

dentin
 Regeneration Pulpotomy
(inductive, reparative)

Calcium hydroxide
Bone Morphogenic Proteins

MTA
Enriched collagen

Osteogenic protein

Freezed dried bone

13
Formation of dentin bridge
Classification ??

14
 Formocresol
introduced in 1904 by Buckley

Buckley contended that equal parts of formalin and

tricresol would react chemically with the intermediate &
end products of pulp inflammation to form a “new,
colorless, and non-infective compound of a harmless
nature.”

Buckley’s Formocresol
Formaldehyde 19%
Tricresol 35%
Glycerin 15%
Water 31% 15
 Formocresol
Mechanism of action

In spite of histologic studies that showed formalin,

creosol, and paraformaldehyde to be connective tissue
irritants, it was recognized early that formocresol is an
efficient bactericide.
It was also found to have the ability to prevent tissue autolysis by
the complex chemical binding of formaldehyde with peptide
groups of side chain amino acids without changing the basic
structure of protein molecule.

16
Fixation of the tissue
directly under the medicament was apparent. After a 7-
to 14-day application, the pulps developed three distinctive
zones: (1) a broad eosinophilic zone of fixation,
(2) a broad pale-staining zone with poor cellular
definition, and (3) a zone of inflammation diffusing
apically into normal pulp tissue. After 60 days, in a limited
number of samples, the remaining tissue was
believed to be completely fixed, appearing as a strand of
eosinophilic fibrous tissue.

17
 One
One Visit
Visit devitalization
devitalization

Formocresol Pulpotomy

first approach to pulpotomy treatment of primary teeth

introduced by Sweet in 1930 as multiple-visit technique

used to mummify the tissue completely

Doyle in 1962 used a two visit procedure (Complete devitalization)

Spedding in 1965 gave 5 minutes protocol (Partial devitalization)

currently 4 minutes application time is used 18

 Formocresol Pulpotomy
Procedure
Anesthetize the tooth & isolation with rubber dam

Access cavity preparation done & all caries removed

The entire roof of the pulp chamber is removed using a high-speed bur

All the coronal pulp is amputated with a slow-speed bur or spoon excavator

Pulp chamber is thoroughly washed with saline to remove all debris

Hemorrhage is controlled by slightly moistened cotton pellets placed over pulp

Apply diluted formocresol to the pulp using a cotton pellet

Cavity filled with ZOE paste & permanent restoration

19
Stainless steel crown placed
20
 Formaldehyde ??

Toxic effects ??

Procedure of formocresol pulpotomy ??

21
Alternatives to formocresol
in primary teeth

22
 Preservation approach

ZOE Pulpotomy
 Zinc oxide-eugenol (ZOE) was the first agent to used for preservation.

 Studies showed that eugenol possesses destructive properties, and

cannot be placed directly on pulp.

 The success rate of ZOE pulpotomy was much less than formocresol
pulpotomy.

 Resultant inflammation & internal resorption were the causes of

failure.

23
 Preservation approach

Glutaraldehyde pulpotomy

 It was suggested by Gravenmade.

 Kopel in an initial study used 2% Glutaraldehyde and suggested that

it can be used in primary teeth pulpectomies.

Mechanism of action

The histologic picture of a Glutaraldehyde treated pulp shows a zone

of superficial fixation with very little underlying inflammation, so a
larger amount of radicular pulp tissue remained vital.

24
 Preservation approach

Glutaraldehyde pulpotomy

Advantages Disadvantages

 Superior fixation by cross

 Solution is unstable
linkage with proteins
 Excellent antimicrobial
 Neither optimum concentration
 Self limiting penetration nor application time has been
established
 Less necrosis of pulpal tissues

 Rapidly metabolized  Lower levels of clinical success

with increasing time
 Less toxicity

 Less systemic distribution

25
As compared to formocresol
 Preservation approach

Ferric sulfate Pulpotomy

Ferric sulfate is a non-aldehyde chemical which has been used

commonly as an astringent.

Mechanism of action

 It is still unclear. It was proposed that Ferric sulfate might prevent

problems encountered with clot formation and thereby minimize the
chances for inflammation and internal resorption.
 Possibly the metal-protein clot at the surface of the pulp stumps acts as
a barrier to the irritative components of the subbase.

26
 Preservation approach

Ferric sulfate Pulpotomy

Application
 a 15.5% solution of ferric sulfate is applied to the radicular pulp stumps
for 10 to15 seconds.
 It may be applied using a cotton pellet or by allowing small droplets of
the solution to drip from a burnisher tip onto the surface of the pulp
tissue.

Success

 Both ferric sulfate and formocresol pulpotomies similarly give good

clinical and radiographic results, with high tooth survival rate.
27
Ferric sulfate Pulpotomy

Preservation approach
MTA Pulpotomy

29
• Surely we agree that the ideal pulpotomy treatment
• should leave the radicular pulp vital and healthy and
• completely enclosed within an odontoblast-lined dentin
• chamber. In this situation, the tissue would be isolated
• from noxious restorative materials in the chamber,
• thereby diminishing the chances of internal
• resorption. Additionally, the odontoclasts of an
• uninflamed pulp could enter into the exfoliative process
• at the appropriate time and sustain it in a physiologic
• manner. Implied in this scenario is the induction
• of reparative dentin formation by the pulpotomy agent.
• Unlike the other two categories for pulp treatment, the
• rationale for the developing field of regeneration is
• actually based on sound, biologic principles.
30
 Formulation of a One-Fifth Dilution
of Formocresol Solution
1 part Buckley’s formocresol solution is mixed with:
• 1 part distilled water and 3 parts glycerin.
A 5-minute application resulted in surface fixation of
normal tissue, whereas an application sealed in for 3
days produced calcific degeneration.

They concluded
that formocresol pulpotomy in primary pulp therapy
may be classified as either vital or nonvital, depending on the duration of the
formocresol application.

32
a wide range of pulpal reactions occurred, from normal pulps to total
chronic inflammation. In most instances, however, the
pulp tissue in the apical region was vital with minimal
inflammation, which was in agreement with many
other studies. It was concluded from both studies that
the formocresol method should be regarded as only a
means to keep primary teeth with pulp exposures functioning
for a relatively short period of time.

33
• Correct diagnosis is essential to ensure the clinician
• that inflammation is limited to the coronal pulp.208
• Biopsy studies of pulp tissue removed from the opening
• of root canals under pulpotomies have demonstrated
• the unreliability of clinical assessments in primary
• teeth.192 Radiographic examinations are therefore necessary
• to confirm the need for pulpotomy therapy in
• primary teeth. It is judicious to take bitewing and periradicular
• radiographs so that the depth of caries may
• be observed and the condition of the periradicular tissues
• determined.

34
One-Appointment Pulpotomy. Indications. This
method of treatment should be carried out only on
those restorable teeth in which it has been determined
that inflammation is confined to the coronal portion of
the pulp. When the coronal pulp is amputated, only
vital, healthy pulp tissue should remain in the root
canals (Figure 17-10).
Contraindications. Teeth with a history of spontaneous
pain should not be considered. If profuse
hemorrhage occurs on entering the pulp chamber, the
one-step pulpotomy is also contraindicated. Other
contraindications are pathologic root resorption, roots
that are two-thirds resorbed or internal root resorption,
interradicular bone loss, presence of a fistula, or
presence of pus in the chamber 35
Two-Appointment Pulpotomy. Indications. The
two-appointment technique is indicated if there is (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, or (5)
a history of spontaneous pain without other contraindications.
The two-step pulpotomy can also be
used when shorter appointments are necessary to facilitate
patient management problems.
Miyamoto suggested
the two-appointment technique for uncooperative children to
minimize chair time, especially for the
initial operative visit
36
• Calcium hydroxide was the first agent used in
• pulpotomies that demonstrated any capacity to induce
• regeneration of dentin. 49 Even from the first, however,
• it was observed that the procedure was not always
• successful.
• It is considered a safe drug relative to
• formocresol, but, other than that, there are no strong
• arguments for its use.

37
• Contraindications. This technique should
not be
• done for teeth that are (1) nonrestorable,
(2) soon to be
• exfoliated, or (3) necrotic.

38
The success rate of pulpotomy treatment depends to a
great extent on the operator’s ability to determine
whether the pulpal inflammation is confined to the
coronal pulp or has possibly progressed into the root
pulp as well. Numerous studies have shown that this
is not possible by clinical means, and that the
diagnosis will be

39
Thank You