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

for primary teeth Topics

Introduction

Definition and rationale.

Indications and contraindications.

Materials and techniques.

Pulpotomy technique (clinical procedures).

Pulpotomy follow up.

Summary and conclusions.

Preservation of the primary teeth until

their time of exfoliation is required to:

a. Maintain arch length,

masticatory function and

esthetics.

Preservation of the primary teeth until

their time of exfoliation is required to:

a. Maintain arch length,

masticatory function and

esthetics.

Preservation of the primary teeth until

their time of exfoliation is required to:

a. Maintain arch length,

masticatory function and

esthetics.

b. Eliminate pain, inflammation

and infection.

Preservation of the primary teeth until

their time of exfoliation is required to:

a. Maintain arch length,

masticatory function and

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

for primary teeth Topics

Introduction

Definition and rationale.

Indications and contraindications.

Materials and techniques.

Pulpotomy technique (clinical procedures).

Pulpotomy follow up.

Summary and conclusions.

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:

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.

Rationale of pulpotomy After the pulpotomy is

performed the remaining

radicular pulp may be:

2. Preserved trough

minimal

inflammatory

insult by using an

haemostatic

agent / laser /

elecrosurgery.

Rationale of pulpotomy After the pulpotomy is

performed the remaining

radicular pulp may be:

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

for primary teeth Topics

Definition, goals and rationale.

Indications and contraindications.

Materials and techniques.

Pulpotomy technique (clinical procedures).

Pulpotomy follow up.

Summary and conclusions.

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.

Contraindications for pulpotomy

Positive percussion test.

The result of behavior

problems and/or

food impaction.

Contraindications for pulpotomy

Tooth restorability.

Contraindications for pulpotomy

Proximity of exfoliation,

Contraindications for pulpotomy

Irreversible pulp damage.

Contraindications for pulpotomy

Irreversible pulp damage.

Pulpotomy treatment

for primary teeth Topics

Definition and rationale.

Indications and contraindications.

Materials and techniques.

Pulpotomy technique (clinical procedures).

Pulpotomy follow up.

Summary and conclusions.

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.

Pulpotomy: materials / techniques

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.

Pulpotomy: materials / techniques

Calcium hydroxide.

Electrosurgery.

Laser.

Glutaraldehyde.

Collagen.

Mineral trioxide aggregate (MTA).

Formocresol.

Diluted formocresol.

Ferric sulfate.

Pulpotomy: materials / techniques

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.

Calcium hydroxide.

Electrosurgery.

Laser.

Glutaraldehyde.

Collagen.

Mineral trioxide aggregate (MTA).

Formocresol.

Diluted formocresol.

Ferric sulfate.

Pulpotomy: materials / techniques

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

Pulpotomy: electrosurgery

Requires the purchase of special

equipment; an electrosurgery dental

electrode.

$ 1000.00

Pulpotomy: electrosurgery

Calcium hydroxide.

Electrosurgery.

Laser.

Glutaraldehyde.

Collagen.

Mineral trioxide aggregate (MTA).

Formocresol.

Diluted formocresol.

Ferric sulfate.

Pulpotomy: materials / techniques

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

Calcium hydroxide.

Electrosurgery.

Laser.

Glutaraldehyde.

Collagen.

Mineral trioxide aggregate (MTA).

Formocresol.

Diluted formocresol.

Ferric sulfate.

Pulpotomy: materials / techniques

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.

Pulpotomy: glutaraldehyde

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.

Pulpotomy: glutaraldehyde

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).

Pulpotomy: glutaraldehyde

Calcium hydroxide.

Electrosurgery.

Laser.

Glutaraldehyde.

Collagen.

Mineral trioxide aggregate (MTA).

Formocresol.

Diluted formocresol.

Ferric sulfate.

Pulpotomy: materials / techniques

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.

Calcium hydroxide.

Electrosurgery.

Laser.

Glutaraldehyde.

Collagen.

Mineral trioxide aggregate (MTA).

Formocresol.

Diluted formocresol.

Ferric sulfate.

Pulpotomy: materials / techniques

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

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.

Pulpotomy: mineral trioxide aggregate

Manf#: 1124-47

UPC#: 039645112441

Manf: QUIKRETE CO.

PORTLAND CEMENT 47LB

Retail Price: $10.55

Regular Price: $9.59

Checkout Price: $8.63

Pulpotomy: mineral trioxide aggregate

$330.00 to 425.00

Pulpotomy: mineral trioxide aggregate

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.

Calcium hydroxide.

Electrosurgery.

Laser.

Glutaraldehyde.

Collagen.

Mineral trioxide aggregate (MTA).

Formocresol.

Diluted formocresol.

Ferric sulfate.

Pulpotomy: materials / techniques

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.

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Pulpotomy: formocresol (full strength or diluted)

Calcium hydroxide.

Electrosurgery.

Laser.

Glutaraldehyde.

Collagen.

Mineral trioxide aggregate (MTA).

Formocresol.

Diluted formocresol.

Ferric sulfate.

Pulpotomy: materials / techniques

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.

Pulpotomy: ferric sulfate

Comparisons

Pulpotomy: materials / techniques

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;32:404407.

Comparisons Pulpotomy: materials / techniques

Comparisons

Pulpotomy: materials / techniques

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

Pulpotomy: materials / techniques

MTA induces less

undesirable responses

and may be FCs 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

Pulpotomy: materials / techniques

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

Pulpotomy: mineral trioxide aggregate

$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

Pulpotomy: materials / techniques

Comparisons

Pulpotomy: materials / techniques

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

Pulpotomy: materials / techniques

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

for primary teeth Topics

Definition and rationale.

Indications and contraindications.

Materials and techniques.

Pulpotomy technique (clinical procedures).

Pulpotomy follow up.

Summary and conclusions.

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

Technique: caries removal

c. If a small carious pulp exposure is disclosed, evaluate the pulp condition, and

perform a complete coronal pulpotomy,

complete caries removal.

Technique: caries removal

Judge the condition of the

exposed pulp based on the pulp

tissue color, hemorrhage (none,

moderate, profuse).

Technique: caries removal

If the pulp color is vivid red, the

bleeding is moderate, proceed

with the pulpotomy.

Technique: caries removal

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: caries removal

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

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

open a wide access to the pulp chamber

with high-sped.

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

open a wide access to the pulp chamber

with high-sped.

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

open a wide access to the pulp chamber

with high-sped.

Technique: pulpotomy

2. Judge the pulp condition based

on the pulp tissue color,

hemorrhage (none, moderate,

profuse).

Technique: pulpotomy

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.

Technique: pulpotomy

Removing the coronal pulp

Technique: pulpotomy

Removing the coronal pulp

using a sharp excavator

Technique: pulpotomy

Removing the coronal pulp

Using slow speed large round bur

Technique: pulpotomy

Removing the coronal pulp

Using a 330 high speed bur

Technique: pulpotomy

Place a cotton pellet to attain hemostasis

Technique: pulpotomy

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.

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.

Technique: pulpotomy

Calcium hydroxide Formocresol. Diluted formocresol. Glutaraldehyde. Ferric sulfate. Mineral trioxide aggregate. Electrosurgery. Laser. Collagen.

Pulpotomy: materials / techniques

Calcium hydroxide Formocresol. Diluted formocresol. Glutaraldehyde. Ferric sulfate. Mineral trioxide aggregate. Electrosurgery. Laser. Collagen.

Pulpotomy: materials / techniques

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.

Calcium hydroxide Formocresol. Diluted formocresol. Glutaraldehyde. Ferric sulfate. Mineral trioxide aggregate. Electrosurgery. Laser. Collagen.

Pulpotomy: materials / techniques

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.

Pulpotomy: ferric sulfate

Pulpotomy: ferric sulfate

Technique: pulpotomy

Apply FS to pulp stumps

for 15 seconds.

Ferric sulfate

3. Rinse with water.

4. Evaluate the pulp stumps.

Pulpotomy: ferric sulfate

Technique: pulpotomy

7. Fill the pulp chamber with IRM.

Technique: pulpotomy

7. Fill the pulp chamber with IRM.

8. Restore the tooth (preferably with a

crown)

Technique: pulpotomy

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

for primary teeth Topics

Definition and rationale.

Indications and contraindications.

Materials and techniques.

Pulpotomy technique (clinical procedures).

Pulpotomy follow up.

Summary and conclusions.

Clinical and radiographic. Gingival and periodonatal health.

Pulpotomy / follow up

Clinical and radiographic. Parulis / fistula.

Pulpotomy / follow up

Clinical and radiographic. Obliteration.

Pulpotomy / follow up

Clinical and radiographic. Interadicular radiolucencies.

Pulpotomy / follow up

Clinical and radiographic. Periodontal health.

Pulpotomy / follow up

Clinical and radiographic. Internal / external abnormal root

resorption.

Pulpotomy / follow up

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.

Pulpotomy / follow up

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

for primary teeth Topics

Definition and rationale.

Indications and contraindications.

Materials and techniques.

Pulpotomy technique (clinical procedures).

Pulpotomy follow up.

Summary and conclusions.

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