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Pulpotomy treatment for

primary teeth

2010 National Primary

Oral Health Conference

October 24-27

Gaylord Palm, Orlando, Florida

Enrique Bimstein

Professor of Pediatric Dentistry

University of Florida College of Dentistry.

Pulpotomy treatment

for primary teeth Goal

The participants will become

familiar with the basic

knowledge and procedures

required for the performance of

the pulpotomy treatment in

primary teeth.

Pulpotomy treatment

for primary teeth Topics

Introduction

Definition and rationale.

Indications and contraindications.

Materials and techniques.

Pulpotomy technique (clinical procedures).

Pulpotomy follow up.

Summary and conclusions.

Pulpotomy treatment


Introduction







Preservation of the primary teeth until

their time of exfoliation is required to:

a. Maintain arch length,

masticatory function and

esthetics.





esthetics.





esthetics.

b. Eliminate pain, inflammation

and infection.





esthetics.

b. Eliminate pain, inflammation

and infection.

c. Prevent any additional pain or

damage to the oral tissues.

Despite all the

prevention

strategies,

childhood caries

is still a fact that

we confront

every day in the

clinic.

The retention of pulpally

involved primary teeth

until the time of normal

exfoliation remains to be

a challenge.

Primary teeth with

cariously exposed vital

pulps should be treated

with pulp therapies that

allow for the normal

exfoliation process.

The retention of pulpally

involved primary teeth

until the time of normal

exfoliation remains to be

a challenge.

Primary teeth with

cariously exposed vital

pulps should be treated

with pulp therapies that

allow for the normal

exfoliation process.

Pulpotomy treatment


Introduction







Definition of pulpotomy

Surgical excision of a vital tooth

pulp.

Surgical removal of a portion of

the dental pulp (levels may vary).

Amputation of the coronal portion

of the pulp, and treatment of the

remaining radicular portion in

order to preserve the vitality of

the remaining pulp tissue.

Rationale of pulpotomy

Pulps with a carious

exposure show a

very limited potential

for pulp recovery, as

the result of

bacterial infection of

the pulp.

Therefore, the infected pulp (coronal

or complete) needs to be removed.

Rationale of pulpotomy

The pulpotomy

treatment is based

on the rationale that

the radicular pulp

tissue is healthy, or

capable of healing,

after amputation of

the infected coronal

pulp.

Rationale of pulpotomy After the pulpotomy is

performed the remaining

radicular pulp may be:




1. Rendered inert

by using

formocresol

that is

bactericidal and

“fixes” the pulp

tissue.




2. Preserved trough

minimal

inflammatory

insult by using an

haemostatic

agent / laser /

elecrosurgery.




3. “Encouraged” to

form a dentin

bridge using

calcium hydroxide

or mineral trioxide

aggregate (MTA).

Rationale of pulpotomy Pulpectomies in

primary teeth are

possible but relatively

complicated and time

consuming.

Root canal filling

materials may interfere

with the normal

exfoliation process of

the primary teeth.

Rationale of pulpotomy A concept that

pulpectomy or

extraction should be

used in cases of vital

primary teeth with

carious exposures

instead of a pulpotomy

has been mentioned in

the literature. Coll JA. Indirect pulp capping and primary teeth: is

the primary tooth pulpotomy out of date? Pediatr

Dent 2008; 30(3): 231-6.

Pulpotomy treatment


Definition, goals and rationale.






Indications for pulpotomy

a. Pulp exposure

caused by

caries: “small”

pulp exposure.

b. Coronal pulp is

still vital.

c. Radicular pulp is

considered to be

“normal”.

Contraindications for pulpotomy

• Preoperative symptoms.

Spontaneous pain

may be the result of

food impaction

Swelling,

spontaneous pain,

etc.


• Positive percussion test.

The result of behavior

problems and/or

food impaction.


• Tooth restorability.


• Proximity of exfoliation, <2/3

of root length. (?)


• Irreversible pulp damage.


• Irreversible pulp damage.

Pulpotomy treatment








What should be

the

characteristics

of an ideal

pulpotomy

material/

technique?

Pulpotomy: materials / techniques

Pulpotomy: materials / techniques The ideal pulpotomy technique / dressing material should be:

simple.

done 1 appointment

and require a short

period of time.

have a high success

rate.

be bactericidal.

promote healing.


harmless to the pulp

and surrounding

structures and

promotes healing

(“biological”).

compatible with the

normal process of root

resorption.

not expensive.

The ideal pulpotomy technique / dressing material should be:

• Calcium hydroxide.

• Electrosurgery.

• Laser.

• Glutaraldehyde.

• Collagen.

• Mineral trioxide aggregate (MTA).

• Formocresol.

• Diluted formocresol.

• Ferric sulfate.



• Electrosurgery.

• Laser.

• Glutaraldehyde.

• Collagen.


• Formocresol.


• Ferric sulfate.


Pulpotomy: calcium hydroxide

Rationale

The use of calcium

hydroxide as a pulp

dressing material after

pulpotomy in primary

teeth is expected to

facilitate the formation of

a dentine bridge

(“barrier”) and promote

the healing of the

radicular pulp tissue.

Pulpotomy: calcium hydroxide

Radiographic study,103 teeth

Success rate of 31%. Among the

unsuccessful teeth, 69% showed evidence of

internal resorption.

The high failure rate in calcium hydroxide

pulpotomies can be attributed to:

Calcium hydroxide has no beneficial

effect on the inflamed pulp.

The creation of an extrapulpal blood cloth. Via W. Evaluation of deciduous molars treated by pulpotomy andcalcium hydroxide. J Oral

Surg 3:171, 1974.


• Electrosurgery.

• Laser.

• Glutaraldehyde.

• Collagen.


• Formocresol.


• Ferric sulfate.


Rationale

• Is a non pharmaceutical

technique.

• Its mechanism of action is

the cauterization of the

superficial pulp tissue Sheller B. Electrosurgical pulpotomy: a pilot study in humans.

Journal of endodontics 13:69-76,1987

Pulpotomy: electrosurgery

Rationale

• A layer of coagulation necrosis that is

caused by the electrosurgery

application, provides a barrier between

healthy radicular tissue and any base

material placed in the pulp chamber.

• The odontoblasts are stimulated to

form a dentin bridge and the tooth is

maintained in the arch with vital

radicular tissue until it exfoliates. Sheller B. Electrosurgical pulpotomy: a pilot study in humans.

Journal of endodontics 13:69-76,1987


Requires the purchase of special

equipment; an electrosurgery dental

electrode.

±$ 1000.00



• Electrosurgery.

• Laser.

• Glutaraldehyde.

• Collagen.


• Formocresol.


• Ferric sulfate.


Pulpotomy: laser

Rationale

Non-pharmaceutical technique.

It creates a superficial zone of

coagulation necrosis that

remains compatible with the

underlying tissue.

pulps retain their vitality and

capability of normal pulp

healing.

Pulpotomy: laser


• Electrosurgery.

• Laser.

• Glutaraldehyde.

• Collagen.


• Formocresol.


• Ferric sulfate.


Rationale.

Has been suggested as an

alternative to formocresol as

a pulpotomy agent , based on

its superior fixative

properties, low antigenicity,

and low toxicity.

Pulpotomy: glutaraldehyde

high molecular weight that

limits its tissue penetration.

has a self-limiting penetration,

hence, reduces the extent of

inflammatory response.

superficial fixation with very

little underlying inflammation.


• In a 2% solution destroys fungi,

viruses, and bacteria.

• It is considered to be better than

formocresol since:

GA does not diffuse trough the

apical foramen.

GA does not penetrate the

periapical tissues as

formocresol.


A normal pulp is seen below

“glutaraldehyde pulps”,

whereas below “formocresol

pulps” there is inflammation, or

“mummification”. However, the material/technique was

not well accepted by the pediatric

dentists; may be since it is still an

aldehyde (similar to formocresol).



• Electrosurgery.

• Laser.

• Glutaraldehyde.

• Collagen.


• Formocresol.


• Ferric sulfate.


Pulpotomy materials / collagen

Rationale Biological non pharmacological material

that may induce tissue healing.

Biological mineral formation initiates

within collagen fibers

Collagen gels may provide an appropriate

scaffolding for tissue formation.

Substantial tissue healing with an acid-

soluble autologous skin collagen solution. (Bimstein and Shoshan, 1981).

Pulpotomy materials / collagen

However, • Animal product (skin)

• May cause allergies (to tissue or to

antibiotics).

• A commercial preparation of collagen was

associated with pulpal inflammation and

necrosis.

• Naturally sourced collagen is not a

promising material for biological

approaches to vital pulp therapy.


• Electrosurgery.

• Laser.

• Glutaraldehyde.

• Collagen.


• Formocresol.


• Ferric sulfate.


Rationale

Prevents microleakage.

Biocompatible.

Promotes regeneration of

original tissues when it is

placed in contact with the

dental pulp or periradicular

tissues.

Pulpotomy: mineral trioxide aggregate


Rationale

Not been found to

induce internal

resorption, which has

been observed in teeth

treated with some

other medicaments.

• MTA is a fine hydrophilic powder developed

by Mahmoud Torabinejad in Loma Linda

University.

• Consists of tricalcium silicate, tricalicum

aluminate, tricalcium oxide, silicate oxide

and bismuth oxide.

• Each pack of MTA comes with a pre

measured unit dose of water for

convenience in mixing.


http://ipj.quintessenz.de/index.php?content=issues&doc=zoomimg&select=153&file=abb02gr.jpg

Manf#: 1124-47

UPC#: 039645112441

Manf: QUIKRETE CO.

PORTLAND CEMENT 47LB

Retail Price: $10.55

Regular Price: $9.59

Checkout Price: $8.63


$330.00 to 425.00



Portland cement may

serve as an effective

and less expensive

MTA substitute in

primary molars

pulpotomies. Sakai VT et al. Pulpotomy of human

primary molars with MTA and Portland

Cement: a randomized controlled trial.

British Dental Journal 2009.



• Electrosurgery.

• Laser.

• Glutaraldehyde.

• Collagen.


• Formocresol.


• Ferric sulfate.


Rationale

• Excellent clinical success!

• Releases formaldehyde

which may diffuse trough

the pulp fixating (mummify)

the tissue (?).

• Does not promote pulp

healing.

Pulpotomy: formocresol (full strength or diluted)

The rationale of fixation

is that we may create a

tolerable irritation

which replaces an

intolerable infection

caused by bacteria.

?????????????????

Pulpotomy: formocresol (full strength or diluted)


• Electrosurgery.

• Laser.

• Glutaraldehyde.

• Collagen.


• Formocresol.


• Ferric sulfate.


Rationale

Is a nonaldehyde agent that produces

haemostasis at pulp stumps by

chemically sealing blood vessels.

The haemostasis takes place by

agglutination of blood protein, without

the presence of a blood clot, which

suggested that preventing clot formation

might minimize the chances for chronic

inflammation.

Pulpotomy: ferric sulfate

Rationale

Induces favorable histological

results in the form of secondary

dentin and bridging.

Retention of maximum vital

tissue and virtual conservation

of the radicular pulp without

induction of reparative dentin.


• Comparisons


Laser (n=68): 97 % and 94.1 % clinical and

radiographic success respectively, follow

up for 6 to 64 months.

Formocresol (n=69): 85.5and 78.3% clinical

and radiographic success respectively,

follow up for 9 to 66 months.

Liu J. Effect of ND:YAG laser pulpotomy on human primary

molars. J Endod 2006;32:404–407.

• Comparisons Pulpotomy: materials / techniques

• Comparisons


Currently available evidence

suggests MTA compared to

FC, FS and CH resulted in

significantly higher clinical

and radiographic success. Ng et al. Mineral trioxide aggregate as a pulpotomy medicament: an

evidence based assessment. Eur Arch Paediatr Dent 9:58-3, 2008.

• Comparisons


MTA induces less

undesirable responses

and may be FC’s most

suitable replacement. Peng L et al. Evaluation of the formocresol versus

mineral trioxide aggregate primary molar pulpotomy: a

meta analysis. Oral Surg Oral Med Oral Pathol Oral Radiol

Endod 102:e40-e44, 2006.

• Comparisons


MTA is superior to CH and

equally effective as a pulpotomy

dressing in primary mandibular

molars . Internal resorption was

the most common radiographic

finding up to 24 months after

pulpotomy. Moretti et al. The effectiveness of mineral trioxide aggregate.

Calcium hydroxide and formocresol for pulpotomies in primary

teeth. International Endodontic Journal 41:545-555, 2008.

Manf#: 1124-47

UPC#: 039645112441

Manf: QUIKRETE CO.

PORTLAND CEMENT 47LB

Retail Price: $10.55

Regular Price: $9.59

Checkout Price: $8.63


$330.00 to 425.00

Portland cement may become the material

of choice for pulpotomies in primary teeth.

Success %

Clinical Radiographic

Electrosurgery 96% 84%

Formocresol 100% 92%

Dean JA et al. Comparison of electrosurgical and formocresol pulpotomy

procedures in children (n=25/25, 5 month follow up).

http://onlinelibrary.wiley.com/doi (cited 09/02/2010

• Comparisons


http://onlinelibrary.wiley.com/doi

• Comparisons


In human carious primary

molars with reversible coronal

pulpitis, pulpotomies

performed with either

formocresol or ferric sulfate

are likely to have similar

clinical/radiographic success. Loh A et al. Evidence based assessment: evaluation of the

formocresol versus ferric sulfate. Pediar Dent 26:401-9, 2004.

• Comparisons


Ferric sulfate, because of its lower toxicity,

may become a replacement for

formocresol in primary molar teeth.

Ibricevic H et al. Ferric sulfate and formocresol in pulpotomy of primary

molars: long term follow-up study. Eur J Pediatr Dent. 4:28-32, 2003.

Success %

Clinical Radiographic

Ferric sulfate 96.4% 92.0%

Formocresol 97.5% 94.6%

Pulpotomy treatment








After completion of removing the caries

from the dentin - enamel junction

remove the caries located at the

surface(s) located close to the pulp with

a large round bur or large spoon sharp

excavator.

Technique: caries removal


caries%20removal.avi

c. If a “small” carious pulp exposure is

disclosed, evaluate the pulp condition, and

perform a complete coronal pulpotomy,

complete caries removal.


Judge the condition of the

exposed pulp based on the pulp

tissue color, hemorrhage (none,

moderate, profuse).


If the pulp color is vivid red, the

bleeding is moderate, proceed

with the pulpotomy.


If the pulp color is dark, or there is

no bleeding, or profuse bleeding, a

pulpotomy is contraindicated and

a pulpectomy or extraction is

required.


Technique: pulpotomy

1.Open a wide access to the pulp

chamber with high-sped.

2. Judge the pulp condition based

on the pulp tissue color,

hemorrhage (none, moderate,

profuse).

3. Remove the coronal pulp tissue

with high speed, low speed or a

sharp large spoon excavator.

4. Observe the pulp stumps and judge

the condition of the radicular pulp

(color, hemorrhage).

5. Obtain haemostasis (cotton pellet).

6. Place the pulp dressing material of

your choice and evaluate the pulp

stumps (no more bleeeding).

7. Fill the pulp chamber with IRM.

8. Restore the tooth (preferably with a crown)


Technique: pulpotomy 1. After complete removal of the caries,

open a wide access to the pulp chamber

with high-sped.



with high-sped.



with high-sped.

//hsc-fs-dental.ad.ufl.edu/dental57/home/bimstein/My Documents/CE projects 2010 - 11/NPOH October 2010/NPOH lectures/Pulpotomy Bimstein/opening the pulp chamber.avi


2. Judge the pulp condition based

on the pulp tissue color,

hemorrhage (none, moderate,

profuse).


3.The technique for removal of the

coronal pulp tissue is the same

for every material you decide to

use as a pulp dressing material.

You may use a sharp excavator,

slow speed with a large round

bur, or high speed with a 330

tungsten bur.


Removing the coronal pulp



using a sharp excavator



Using slow speed large round bur

//hsc-fs-dental.ad.ufl.edu/dental57/home/bimstein/My Documents/CE projects 2010 - 11/NPOH October 2010/NPOH lectures/Pulpotomy Bimstein/remove pulp round bur & rinse 2.avi



Using a 330 high speed bur

//hsc-fs-dental.ad.ufl.edu/dental57/home/bimstein/My Documents/CE projects 2010 - 11/NPOH October 2010/NPOH lectures/Pulpotomy Bimstein/removing pulp 330.avi


Place a cotton pellet to attain hemostasis

removing%20pulp%20330.avi


Evaluate hemostasis

“Unstoppable” bleeding No bleeding

What if you do not

achieve hemostasis? Check for ledges and remove them if present, by widening the opening.

//hsc-fs-dental.ad.ufl.edu/dental57/home/bimstein/My Documents/CE projects 2010 - 11/NPOH October 2010/NPOH lectures/Pulpotomy Bimstein/remove pulp round bur & rinse 2.avi

Re-evaluate hemostasis

What if you still do not

achieve hemostasis?

Perform a deeper

pulpotomy,

or “partial

pulpectomy” by

penetrating the

pulp canals with a

small round bur

or……..

What if you still do not

achieve hemostasis?

6. Place the pulp dressing material of

your choice and re-evaluate the

pulp stumps.


• Calcium hydroxide

• Formocresol.


• Glutaraldehyde.

• Ferric sulfate.

• Mineral trioxide aggregate.

• Electrosurgery.

• Laser.

• Collagen.



• Formocresol.


• Glutaraldehyde.

• Ferric sulfate.


• Electrosurgery.

• Laser.

• Collagen.


• Full strength or diluted

Pulpotomy materials / formocresol

1.Control hemorrhage with

cotton pellets.

2.Apply a cotton pellet

moistoned with FC to the pulp

stumps for 5 minutes.

3.Evaluate the pulp stumps.

4.Fill the pulp chamber with IRM.


• Formocresol.


• Glutaraldehyde.

• Ferric sulfate.


• Electrosurgery.

• Laser.

• Collagen.


• Ferric sulfate

1. Control hemorrhage with

cotton pellets.

2. Apply (rub) FS to pulp

stumps for 15 seconds.

3. Rinse with water.

4. Evaluate the pulp stumps.




Apply FS to pulp stumps

for 15 seconds.

//hsc-fs-dental.ad.ufl.edu/dental57/home/bimstein/My Documents/CE projects 2010 - 11/NPOH October 2010/NPOH lectures/Pulpotomy Bimstein/apply FS.avi

• Ferric sulfate

3. Rinse with water.

4. Evaluate the pulp stumps.






//hsc-fs-dental.ad.ufl.edu/dental57/home/bimstein/My Documents/CE projects 2010 - 11/NPOH October 2010/NPOH lectures/Pulpotomy Bimstein/IRM.avi

8. Restore the tooth (preferably with a

crown)


Pulpotomies

success rates were

79.9% for teeth

restored with a SSC

and 60% for those

restored with

amalgam. Sonmez et al. Success rate of calcium

hydroxide pulpotomy in primary molars

restored with amalgam and stainless steel

crowns. British Dental Journal 208:e18, 2010.

Pulpotomy treatment








Clinical and radiographic. • Gingival and periodonatal health.

Pulpotomy / follow up

Clinical and radiographic. • Parulis / fistula.


Clinical and radiographic. • Obliteration.


Clinical and radiographic. • Interadicular radiolucencies.


Clinical and radiographic. • Periodontal health.


Clinical and radiographic. • Internal / external abnormal root

resorption.


Both, ferric sulfate

(22%) and formocresol

(20%) pulpotomies

can lead to internal

resorption Vargas KG. Radiographic success of ferric sulfate and

formocresol pulpotomies in relation to early exfoliation. Ped

Dent 27:233-7, 2005

Internal resorption self-repair?

Clinical and radiographic. • Early exfoliation.


Both ferric sulfate (11%)

and formocresol (10%)

pulpotomies can lead to

premature exfoliation of

primary teeth, with the

subsequent need for

orthodontic space

maintenance. Vargas KG. Radiographic success of ferric sulfate and formocresol

pulpotomies in relation to early exfoliation. Ped Dent 27:233-7, 2005

Pulpotomy treatment








The pulpotomy treatment in primary teeth

provides the possibility to preserve vital

primary teeth that had a carious pulp

exposure.

Formocresol is still a very popular

pulpotomy dressing material.

Ferric sulfate is a good alternative and

does not have the possible deleterious side effects of formocresol.

Pulpotomy / summary and conclusions