Many teeth are still lost prematurely even though we know the importance of the teeth and above all we have various techniques to save them. . The primary objective of pulp treatment of an affected tooth is to maintain the integrity and health of oral tissues. Primary teeth that are the baby teeth are replaced by the adult teeth so people do not take them seriously. But the baby teeth are very important. If they are lost prematurely like they are lost before their normal shedding time they can cause lot of problems. The child will have difficulty in chewing the food and it will have adverse effect on his or her general growth and development. The psychological trauma is there to the child. Child has the speech problem. The baby teeth maintain the arch integrity and maintain the space for the eruption of the permanent teeth or the adult teeth but if the baby teeth or the milk teeth are lost before the time the space will be lost and the adult teeth will not erupt in their normal position. It can also cause the development of certain abnormal tongue positions. So, maximum attempts are made to preserve primary teeth in a healthy state until normal exfoliation of teeth occurs.
Pulpotomy refers to coronal removal of the vital pulp tissue. In a tooth there is the crown part and the root part. In the crown part there is coronal pulp and in root there ia root pulp. Some times the cavity is deep but the pulp is not infected or there is pin point exposure but infection is not there. In such cases it is recommended to remove the coronal pulp and save the root pulp. In this way the vitality of the tooth is maintained.
The objective is to remove the inflamed part of the pulp which is followed by the application of calcium hydroxide to the remaining pulp tissue
Indications for Pulpotomy
1. Exposure of the teeth because of caries or by mechanical means.
2.Inflammation limited to coronal pulp
3.Absence of spontaneous pain
4.Absence of swelling or alveolar abscess formation
Contraindications for Pulpotomy
1.History of unprovoked toothache
2.Presence of fistula or swelling
3.Evidence of necrotic/irreversibly damaged pulp
4.Uncontrolled pulpal hemorrhage
5.Periapical or bifurcation radiolucency
6.Pathologic resorption of pulp
8.Primary root length less than 2/3
Buckley’s Formula Of Formocresol
Cresol – 35% Glycerol – 15%
Formaldehyde – 19% Water – 31%
Procedure of Pulpotomy
First of all three parts of glycerin added to one part of distilled water. Then four parts of this preparation to one part of Buckley’s formocresol are added and thoroughly mixed again.
Procedure of Formocresol Pulpotomy
1.Anesthetize the tooth & isolate with rubber dam.
2. Remove caries with high speed straight fissure bur without entering pulp.
3. Remove the dentinal roof with a slow speed round bur for minimal trauma to the roof the pulp.
4. Remove the coronal pulp with a spoon excavator.
5. Clean the pulp chamber with saline.
6. Achieve homeostasis with a cotton pellet.
5. With the help of sterlized cotton pellet apply formacresol to the cavity for four minutes.
8. Place dry cotton pellet over that to avoid contact with oral tissues.
9. Remove cotton pellet, check fixation and zinc oxide eugenol is placed.
10. Recall the patient after 1 week for permanent restoration.
11 Place a stainless steel crown.
Preoperative View of Pulpotomy
Post Operative View of Pulpotomy
Toxic properties of formocresol reported are:
- It has found to be Cytotoxic, mutagenic, carcinogenic.
- It has also been found in periodontal ligament. Bone, dentine and urine when used in the pulpotomities of animals.
- Their antigenocity effects have also been reported.
- Formaldehyde denatures nucleic acids by forming methylol derivatives.
- It affects the biosynthesis and cell reproduction by reacting with DNA and ribonucleic acids.
Three zones have been identified. These are:
- Acidophilic zone: Fixation
- Pale staining zone: Atrophy
- Broad zone of inflammatory cells
Contraindications of Formocresol Pulpotomy
- Spontaneous pain
- Percussion tenderness
- Mobility of the tooth which is pathological.
- Any root resorption which can be internal or external
- Calcification of the pulp
- On X-ray if we see the radiolucency
- Profuse hemorrhage
Two Appointment Pulpotomy
- Sluggish or profuse bleeding at the site.
- Bleeding is difficult to control.
- Slight purulence in the chamber but at the amputation site.
- Thickening of the periodontal ligament.
- 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.
Indication of Cvek’s Pulpotomy
When pulp is exposed by mechanical or bacterial means in young permanent teeth,the remaining radicular tissue is judged by clinical and radiographic cirteria where the root closure is not complete.
Procedure of Cvek’s Pulpotomy
It s calcium hydroxide pulpotomy and is done mostly in the young permanent tooth where it is mandatory to maintain the vitality of thee radicular pulp so that the root formation can be completed. In this the tooth is isolated with rubber dam after giving the anesthesia. By using the round bur at slow speed all the carious material is removed. After this the coronal pulp that is the pulp in the crwn part is removed with the excavater and then we put pressure to stop the bleeding. After the bleeding is stopped calcium hydroxide is applid and then above this the temporary filling material is put. Recall is done and if the tooth is asymptomatic then final filling is done. Finally permanent restoration is done.
Glutaraldehyde Pulpotomy Method
Inflamed tissue that produces toxic products must be fixed rather than be disinfected. So Glutaraldehyde has more fixing properties than formocresol and is also causes less tissue destruction and also appears to be bactericidal. So in Glutaraldehyde Pulpotomy 2% Glutaraldehyde is used instead of Formocresol.
Non Vital Pulpotomy or Mortal Pulpotomy
Ideally speaking pulpotomy is done in the vital tooth and in nonvital tooth pulpectomy is done. But in some cases t is not possible to do the pulpectomy may be because of the nonnegotiable root canals or the patient is cooperating. In such cases mortal pulpotomy is done.
Procedure of Non Vital Pulpotomy Or Mortal Pulpotomy
In the first appointment the necrotic pulp from the pulp chamber is removed and the radicular pulp is treated with the strong antiseptic solution. Then tha cavity is sealed with the temporary restorative material.
In second appointment if the tooth is asymptomatic, antiseptic paste is put in the pulp chamber and above that stainless steel crown is put.
Electro Surgical Pulpotomy Procedure
· The method of procedure in this case as under.
· Tooth is isolated and local anesthesia is given.
· Carious removal is done.
· Sterile cotton is placed to stop the bleeding. Some pressure is applied. As soon as the cotton pellet is removed an electrode s placed 1 to 2 mm above the pulp tissue. It is applied for couple of seconds which is followed by 5 min. of cooling down period. Zinc oxide eugenol paste is placed n the pulp chamber directly above the root stumps. Above this the final restoration is done.
It has received the most recent attention as a formocresol alternative in pulpotomy choices. Ferric sulfate when comes in contact with tissues, it forms a ferric ion-protein complex that mechanically occludes capillaries at the pulpal amputation site. The subjacent pulp tissue is then allowed to heal.
Use of Lasers in Pulpotomy
Application of laser irradiation in vital pulp therapy has been proposed as another alternative to pharmacotherapeutic techniques. Its advantages and disadvantages are the same as for electro surgery.
PULPOTOMY FOLLOW-UP TOOTH
6 MONTHS FOLLOW-UP
12 MONTH FOLLOW-UP
18 MONTH FOLLOW-UP
Factors affecting Success Rates of Pulpotomy
- Accurate pre-operative diagnosis.
- Un-controlled bleeding after pulpal removal.
- Type and timing of final restoration.
Pulpotomy is considered to be Successful when following criteria have been fulfilled
- No pain, sensitivity, swelling or mobility, Signs of infection and inflammation.
- No radiographic evidence of pathologic or external root resorption.
- No evidence of calcification of canals is present.