Pulpoom

Presented by: ROSHNI MAURYA

FINAL YEAR PGT

CONTENTS• Introduction

• Definition

• Rationale

• Objectives

• Indication

• Contraindication

• Classification

• Medicaments used

• Techniques

• Formocresol pulpotomy

• Electrosurgical pulpotomy

• Laser pulpotomy

• Calcium hydroxide pulpotomy

• Glutarldehyde pulpotomy

• Ferric sulphate pulpotomy

• Recent concepts

• Bone morphogenetic protein

• Lyophilized freeze dried

platelet derived preparation

• Enamel matrix derivatives

• Reasons for failure of

pulpotomy therapy

INTRODUCTION

• Primary tooth pulp therapy is aimed at preserving theprimary teeth until normal exfoliation.

• Management of the cariously involved primary tooth wherethe carious lesion approximates the pulp requires aknowledgeable approach to pulp therapy, and a successfuloutcome depends on accurate diagnosis of the status of thepulp prior to therapy.

• Preliminary data gathering and interpretation must befocused on determining whether the primary tooth pulp isnormal, reversibly inflamed, irreversibly inflamed ornecrotic.

• If it is determined to be vital or reversibly inflamed,the vital pulp therapy techniques of pulpotomy orindirect pulp treatment (IPT) are indicated.

• If the pulp is determined to be irreversibly inflamedor necrotic, either a pulpectomy or extraction wouldbe appropriate.

• This presentation is limited to a discussion of

the vital pulp therapy procedure of pulpotomy

for primary teeth.

Definition:

• Complete removal of the coronal portion of the dental pulp,followed by placement of a suitable dressing or medicamentthat will promote healing and preserve the vitality of thetooth (Finn,1985).

• Pulpotomy is defined as the amputation of vital pulp from thecoronal pulp chamber followed by placement of amedicament over the radicular pulp stumps to stimulaterepair, fixation or mummification of the remaining vitalradicular pulp (Braham and Morris)

Rationale: When the coronal pulp is exposed by trauma or operative procedures, or

caries ingress of bacteria, it produces inflammatory changes in thetissue.The surgical excision of the infected and inflamed coronal pulp,the vital uninfected pulpal tissue can be left behind and preserved in theroot canal.

The removal of the inflamed portion of the pulp affords temporary, rapidrelief of pulpalgia and further may undergo repair while completingapexogenesis that is root end development and calcification.

Materials used for this procedure either mummify or fix the tissue orpromote healing by formation of a bridge.

Objectives (AAPD Guidelines )

The radicular pulp should remain asymptomatic without adverse

clinical signs or symptoms such as sensitivity, pain, or swelling.

There should be no postoperative radiographic evidence of

pathologic external root resorption.

Internal root resorption can be self limiting and stable.

The clinician should monitor the internal resorption, removing

the affected tooth if perforation causes loss of supportive bone

and/or clinical signs of infection and inflammation.

There should be no harm to the succedaneous tooth.

• A correct diagnosis of pulp conditions in primary and youngpermanent teeth is important for treatment planning.

• McDonald and Avery have outlined several diagnostic aids inselecting teeth for vital pulp therapy.

• Eidelman et al and Prophet and Miller have emphasized thatno single diagnostic means can be relied on for determining adiagnosis of pulp conditions.

CASE SELECTION

• A suggested outline for determining the pulpal status of cariously involved teeth in children involves the following:

1.Visual and tactile examination of carious dentin andassociated periodontium

2. Radiographic examination ofa. periradicular and furcation areasb. pulp canalsc. periodontal spaced. developing succedaneous teeth

3. History of spontaneous unprovoked pain4. Pain from percussion5. Pain from mastication6. Degree of mobility7. Palpation of surrounding soft tissues8. Size, appearance, and amount of hemorrhage associated with pulp

exposuresEndodontics : Ingle 5th edi

Electric pulp tests are not valid in primary teeth.

• Andreasen et al. Textbook and color atlas of traumaticinjuries to the teeth. 4th ed, 2007

Thermal tests are usually not conducted on primary teeth because of their unreliability.

• Cohen S, Hargreaves K : 9th ed. 2006:822– 82.

Numerous studies have reported the unreliability of electric pulp tests in permanent teeth with open and developing apices.

• J Dent Child 1978;45:199 –202.• J Endod 1986;12:301–5.

• Aust Dent J 1977;22:272–9.

Laser Doppler flowmetry might be of greater help in determining vitality.

• Endod Dent Traumatol 1999;15:284 –90.

• Dent Traumatol 2001;17:63–70

• Endod Top 2003;5:12–25.

Cariously exposed primary teeth, when their retention is more advantageous than extraction.

Vital tooth with healthy periodontium

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

Tooth which is restorable

Tooth with-2/3rd root length

Hemorrhage from the amputation site is pale red & easy to control

INDICATION

Absence of abscess and fistula

No inter-radicular bone loss

No inter-radicular radiolucency

On young permanent tooth

with vital exposed pulp and

incompletely formed apices

CONTRAINDICATION

Persistent tooth ache.

Tenderness on percussion / mobility present.

Root resorption more than 1/3rd of root length.

Large carious lesion with non-restorable crown.

Highly viscous, sluggish hemorrhage from canal orifice which is

uncontrollable.

Evidence of internal resorption Presence of inter radicular bone loss Tooth close to natural exfoliation Medical contraindications ; immuno--compromised patient.

FACTORS THAT AFFECT

PROGNOSIS OF PULPOTOMY:

Size of exposure

Location of exposure

Exposure to saliva

Marginal leakage

Age and status of the pulp (Stahl et al 1970)

Evidence of success in therapy includes the

following:

Vitality of the majority of the radicular pulp

No prolonged adverse clinical signs or symptoms,such as prolonged sensitivity, pain, or swelling

No radiographic evidence of internal resorption

No breakdown of periradicular tissue

No harm to succedaneous teeth

Pulp canal obliteration (abnormal calcification)

CLASSIFICATION

• Pulpotomy can be classified according to treatment objectives

given by Ranley et al:

• Vital pulpotomy

I. Devitalization Pulpotomy (Mummification, Cauterization)

a. Formocresol pulpotomy.

b. Electrosurgical pulpotomy.

c. Laser pulpotomy.

II. Preservation (Minimal devitalization, Non – inductive)

• Gluteraldehyde.

• Ferric sulfate.

III. Regeneration (Inductive, Reparative)

• Calcium Hydroxide.

• Bone morph genetic Protein.

• Mineral trioxide aggregate

II.NON –VITAL PULPOTOMY:

- Beechwood cresol

– Formocresol

Devitalisation:

• The first approach to be used with the intention of“mummifying’ the radicular pulp tissue.

• The term “mummified” has been ascribed to chemicallytreated pulp tissue that is inert, sterilized, metabolicallysuppressed, and incapable of autolysis. This approachinvolved the original two- sitting formocresolpulpotomy, which resulted in complete devitalization ofthe radicular pulp.

• Also included were the 5- minute formocresol and 1:5diluted formocresol techniques, which both result inpartial devitalization with persistent chronicinflammation.

Preservation:

• This approach involved medicaments and techniquesthat provide minimal insult to the orifice tissue andmaintain the vitality and normal histologic appearanceof the entire radicular pulp.

• Pharmacotherapeutic agents included in this categoryare corticosteroids, glutaraldehyde and ferric sulfate.

• Nonpharamcotherpeutic techniques in this categoryinclude electrosurgical and laser pulpotomy.

Regeneration:

• This approach includes pulpotomy agents that have cell-inductive capacity to either replace lost cells or inducesexistent cells to differentiate into hard tissue formingelements.

Examples of true cell- inductive agents include:

– Transforming growth factor- (TGF- ) in the formof bone morphogenetic

– Proteins freeze dried bone

– Mineral trioxide aggregate (MTA)

PULPOTOMY MEDICAMENTS

• Formocresol (Buckley’s formocresol).

• Glutaraldehyde.

• Calcium hydroxide.

• Zinc oxide eugenol.

• Ferric sulphate

• Gysi’s paste

• Easlick’s paste

• Paraform paste

• Cresol

• Enriched collagen phosphate gel

• Collagen calcium phosphate gel

• Freeze Dried bone

• Enamel matrix derivative

Easlick’s Paraformaldehyde Paste

• Paraformaldehyde 1g

• Procaine base 0.03g

• Powered asbestos 0.50g

• Petroleum jelly 125g

• Carmine To color

Materials used for visit pulpotomy

Gysi Triopaste

• Tricresol 10ml

• Cresol 20ml

• Glycerin 4ml

• Paraformaldehyde 20g

• Zinc Oxide eugenol 60g

Paraform Devitalizing paste (Modified Easlick’s Paste)

• Paraformaldehyde 1g

• Lignocaine 0.06g

• Propylene glycol 0.50ml

• Carbowax 1.3g

• Carmine to color

Recent materials

• Propolis.

• Bone Morphegenic Protien

• Lyophilized Freeze Dried Platelet Derived Preperation

• Hydroxy appatite

• Mineral trioxide aggregate

• Bioactive Molecules

• New endodontic cement.

• Calcium enriched cement.

Pulpotomy Techniques:There Are Three Pulpotomy Techniques:

• Vital Formocresol pulpotomy technique: also known as the 1-minuteformocresol.

• Devitalization pulpotomy: This is two- stage technique and reliedupon paraformaldehyde to fix the coronal and radicular pulp tissue.

• Non –vital Pulpotomy: This technique is carried out when theinflammatory process affecting the coronal pulp extends to theradicular pulp leading to an irreversible change in the pulp tissue .

•

Aramentarium For The Pulptomy Technique

• Topical and local Anaesthesia.

• Burs No 330 FG high speed and No 8 RA Slow speed.

• Rubber dam kit.

• Mouth mirror, probe and tweezers.

• Cotton pellets (small).

• Large and small excavators.

• Mixing spatula, flat plastic instrument.

• Formocresol, 1/5 dilution.

• Dappens pot, syringe.

• Zinc oxide eugenol.

• Glass ionomer cement for lutting

• Stainless steel crown

Single Visit Pulpotomy

• Step 1: Administration of local anesthesia

• Step 2: Apply a rubber dam

• Step 3: Use a sterile No.4 or 8 round bur (slow speed) toremove all carious dentin .If possible, remove all carious dentinbefore exposing the pulp horns

• Step 4: Place a No. 330' bur in the high-speed hand piece. Gainocclusal access to the pulp chamber by preparing a Class 1cavity preparation. It is better to make too large an openingthan one that is too small. Remove all overhanging enamel.

• Step 5: Excise the pulpal tissue to the orifices of the rootcanal. Use a large spoon excavator to remove anyremaining pulpal tissue.The pulpal tissue should beamputated to the entrance of the root canals.

• Step 6: After completing the amputation, evaluate thehemorrhage. If the pulpal tissue has been removedcompletely, hemorrhage should be minimal.A vital pulpwith minimal chronic inflammation should achievehemostasis in 3 to 5 minutes.

• Step 7: Over the exposed pulp stump, place sterile cottonpellet moistened (but not saturated) with formocresol,20% dilution.

• Step 8:Leave the formocresol in place for 1 minute, and then

remove the pellet. The pulp stump should appear blackish

brown .If there is bleeding, check for residual pulpal tissue.

Reapply formocresol for 2 minutes.

• Step 9: Fill the pulp chamber to about half its volume with a

thick mixture of zinc oxide-eugenol.

• Step 10:Prepare the tooth for a stainless steel crown

Procedure

Two Visit Pulpotomy

Indications for two-visit pulpotomy procedure in primary teeth are

• Inability to arrest hemorrhage from the amputated pulp stumps during a single visit formocresol pulpotomy.

• Non-vital coronal and/or radicular pulp without the presence of an abscess.

• In two-stage procedure, this involves the use of

paraformaldehyde to fix the entire coronal and

radicular pulp tissue. The paraformaldehyde

paste is most commonly used (Hobson 1970)

• The paste is placed over the pulpal exposure on a small pledget of cottonwool, the larger the exposure then the more successful the outcome.

• The paraformaldehyde paste is sealed into the cavity with a thin mix ofzinc eugenol and left for 1-2 weeks.

• Formaldehyde gas liberated from the paraformaldehyde permeatesthrough the coronal and radicular pulp, fixing the tissues.

• On the second visit, the dressing is removed, there is no need toadminister a local anesthetic as the pulp contents should be nonvital,pulpotomy is carried out and then covered with hard setting zinc oxidecement or alternatively an antiseptic paste (equal parts of eugenol andformocresol with zinc oxide) over the radicular pulp before restoring thetooth.

• Hobson (1970) reported a success rate of 77% after 3 years.

Non Vital Pulpotomy (Mortal Pulpotomy)

• Indications

• When the inflammatory process affecting thecoronal pulp extends to the radicular pulp leadingto an irreversible change in the pulp tissue.

• When the pulp is completely non-vital, wherethere may be an abscess present with or withoutacute cellulites

MEDICAMENTS USED:

Constituents of Beechwood cresol

• 2 Methoxy, 4 methyl phenol (Cresol) : 13%

• Methoxyl phenol (Guaicol) : 47%

• M-Methoxy phenol : 7%

• P-Methoxy phenol : 26%

• Unknown : 7%

TechniqueIst visit:

• The necrotic coronal pulp is first removed, asrecommended in the vital pulpotomy technique.

• The necrotic debris in the pulp chamber is thencleared. If there is sufficient access to the radicular pulpcanals then as much as possible of the necrotic tissue isremoved with a small excavator.

• A small pledget of cotton wool dipped in beechwoodcresol is then sealed into the cavity with temporary zincoxide eugenol cement.

• IInd visit:

• Usually 1-2 weeks later the dressing is removed, provided the signsand symptoms of infection have cleared,

• The cavity is then restored in the same manner as used in the vitalpulpotomy technique.

• If it appears that there is no resolution of the symptoms then thebeechwood cresol should be replaced for a further 1-2 weeks,

• Other medcaments like formocresol and camphoratedmonochlorophenol (Arnold and Rock, 1993) have been equallyeffective, at the second visit, after one to two weeks an antiseptic pastethat is placed over the radicular pulp remnants before restoring thetooth replaces the antiseptic solution.

• Hobson (1970) reported a success rate of 66% after 3 years.

Partial Pulpotomy (Cvek’s Pulpotomy)

• Definition: It is the removal of only the outer layer of

damaged and hyperemic tissue in exposed pulps, is considered

to be a procedure staged between pulp capping and complete

pulpotomy. It is a mode of treatment which is widely used in

the permanent dentition but less so in primary teeth.

Radionale And Advantages

• The main advantage of Partial pulpotomy is that a successful

outcome will allow the continuation of normal development of

the tooth, including further root development and maturation.

Apex formation and thickening of thin root walls may occur in

young teeth.

• The tooth following a partial pulpotomy will retain its natural

color and translucency in comparison to the coronal

discoloration in many teeth undergo after pulpectomy.

• Partial pulpotomy have advantage over complete pulpotomy is

the preservation of cell rich coronal pulp tissue.

Indications• A small and recent pulpal exposure of up to approximately 14 days in a non

carious primary incisor.

• A sufficient tooth structure is present to allow proper restoration and fullcoverage of the crown with a bonded resin- composite strip crown.

• Partial pulpotomy is highly indicated in a very young tooth with a wide- openapex and very thin root dentin walls.

• The decisive factor for selection of the partial pulpotomy and its success is ahealthy, non inflammed and asymptomatic vital pulp.

• During the procedure, an operative diagnosis should be made by assessing thepulpal with regard to the bleeding from the amputation site, including thecolor, viscosity, and ability of the tissue to achieve hemostasis

Contraindications• Exposure is very large or when more than 2 weeks have passes

between injury and treatment time allowing oral contaminants

to cause extensive infection or inflammation beyond 2 to 3

mm of the exposure.

• Purulent drainage.

• History of prolonged pain.

• Necrotic debris in canal.

• Periapical radiolucency.

TechniqueThe clinical procedure is described as follows

• Proper patient management should be achieved with or withoutpremedication.

• Local anesthesia and rubber dam placement should beadministered with the slit technique.

• A no. 330 tungsten bur is used to ampute the pulp close to theexposure site to a depth of 2mm.

• Continuous rinsing of the amputed pulp with saline will assistin achieving hemostasis without blood clot formation within 4minutes (if hemostasis is not achieved, all the coronal tissueshould be removed and a cervical pulpotomy should beperformed).

• A dressing of calcium hydroxide paste should be

placed followed by base/line of glass ionomer

such as Vitrebond.

• The tooth is restored using a bonded resin-

composite strip crown.

• Scheduled follow- ups should be made after 1

month and then every 6 months. A dentin bridge

will begin to form, separating the exposure site

from the rest of the pulp. The bridge may be

evidenced radio graphically after 6 to 8 weeks in

future occlusal/ periapical view.

Formocresol Pulpotomy

• Formocresol was introduced in 1904 by Buckley, whocontended that equal parts of formalin and tricresol wouldreact chemically with the intermediate and end products ofpulp inflammation to form a “new, colorless, and non-infective compound of harmless nature.

• Buckley’s formula of formocresol, consists of tricresol,aqueous formaldehyde, glycerine, and water.

Composition

pH - 5.1

Dilution of formocresol

• Loos and Han have led to the conclusion that a dilute (1: 5concentration) of Buckley’s formocresol applied to tissueachieved the desired cellular response.

• The orginal buckley’s formula for formocresol calls forequal parts of formaldehyde and cresol. The 1:5concentration of this formula is prepared by firstthoroughly mixing three parts of glycerin with one part ofdistilled water, then adding four parts of this diluent toone part of Buckley’s Formocresol and thoroughly mixingagain.

Formocresol concentration

• It is therefore recommended that 1/5th concentration formocresol

be utilized for pulpotomy procedure since it is as effective as and

less damging than the traditional preparation.

• In recent years formocresol has been extensively evaluated using

animal models. It was concluded that 20% dilution causes the

least histologic damage and that a 1 minute application of

formocresol is adequate to produce the desired results.

• Garcia – Godoy (1984) advocated the use of 20% dilution of

formocresol for partial pulpotomies. He showed a success rate

96%.

Step 1: Access opening of the carious tooth.

Step 2: Removal of coronal part of the carious tooth.

Step 3: Formocresol dressing placed on the amputed pulp.

Step 4 : Stainless steel crown placed on the pulpotomised tooth.

PRE AND POSTOPERATIVE

RADIOGRAPHS

Berger- compared effect of formocresol medication with those

ZnOE paste

97% success - formocresol

58% success - ZnOE

Rolling and Thylstrup –(1975) 3 year follow up

91% -3months83% - 12 months78% - 24 months70% - 36 months

• Buckley 1904 – recommended for treating the putrescent pulp

• 5 visit therapy was reduced to 3 visit(1955)

• Sweet (1960), advocated single visit, and placement of ZnOE cement containing some formocresol over the pulp stumps– widely accepted

• Miyamoto 1974 – suggested 2 visit technique for unco-operative children

• Verco and Allen 1984- no difference between single visit and two visit technique

• Kennedy and Curzon highlighted the convenience of single visit technique for child and parent

Effect on succedaneous toothYES –

• Pruhs et al 1977 ,

• Messer et al 1980

NO --

• Wright & Widmer 1979,

• Rolling & Poulsen 1978,

• Fuks & Bimstein 1981,

• Mulder et al 1987

Histologic investigation of the effect of formocresol

on the pulp• Massler and Mansukhani conducted a detailed histologic

investigation of the effect of formocresol on the pulps of 43 human

primary and permanent teeth in multiple treatment intervals.

• Fixation of the tissue directly under the medicament was apparent.

After a 7 to 14-day application, the pulps developed three distinctive

zones:

• A broad eosinophilic zone of fixation

• A broad pale-staining zone with

poor cellular definition

• 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 standard of

eosinophilic fibrous tissue.In general, the results of many histologic

studies on the formocresol pulpotomy have shown that several distinct

zones are usually present in the pulp following the application of the

medicaments.

• Superficial debris along with the dentinal chips at the amputation site

• Eosinophil-stained and compressed tissue

• A palely stained zone with loss of cellular definition

• An area of fibrotic and inflammatory activity

• An area of normal-appearing pulp tissue considered to be vital

Advantages• Commonly available medicament

• Stable at room temperature

• Long shelf life

• High clinical and radiographic success of formocresol pulpotomy

Disadvantages• It is a very caustic medicament.

• In high doses it is toxic.

• Potential systemic absorption and distribution throughout the body.

• It has a mutagenic and carcinogenic potential .

Toxicity • Local toxicity

• The classical description of a 5 minute application is

• Immediately beneath the site of amputation there iseosinophilic tissue interpreted as the zone of fixation.

• The next zone is the pale staining amorphous zone withdiminished cellular and fiber definition which is the result oflipid dissolving property of cresol. Stagnation necrosis as aconsequence of formocresol induced vascular thrombosis.

• Broad zone with inflammatory cells first of acute variety andthen of chronic variety.

• Muller 1978 stated topical application of formalin causesleukoplakia and lesions resembling carcinoma in situ.

• Formocresol seeps in through accessory canals intodeveloping tooth germ and causes enamel defects likehypoplasia and might alter position of underlyingpermanent tooth (Messler 1980)

• Jerell and Ronk 1982 described arrested development ofbicuspid while Grundy and coworkers in 1984 describedcyst in primary teeth treated with formaldehyde

Systemic toxicity

• After systemic administration of formocresol in experimentalanimals, formocresol is distributed throughout the body.Metabolism and excretion of a portion of the absorbedformocresol occur in the kidneys and lungs.

• The remaining drug bound to tissue predominantly in thekidney and lungs. When administered systemically in largedoses, acute toxic effects (e.g., cardiovascular changes, plasmaand urinary enzyme changes, histologic evidence of cellularinjury to the vital organs) were noted.

• The degree of tissue injury appeared to be closely related, withsome of the changes being reversible in the early stages.

• With the use of isotope-labeled, 19% formaldehyde, thepresence of the drug was demonstrated in the lung, liver,kidney, muscle, serum, urine and carbon dioxide after 5-minuteapplication of pulpotomy sites. The concentrations achieved inthe tissues were equivalent to those found after an infusion of30% of the amount placed in the pulp chamber.

• Pashley and Myers et al (1980) in their study on dogsdetermined the fate of the C-formaldehyde following anapplication to pulpotomy sites and confirmed (with theirprevious finding) that C-formaldehyde containing formocresolwas absorbed from pulpotomy sites and appeared in bodyfluids. They concluded that formocresol is absorbed anddistributed rapidly and widely throughout the body withinminutes after being placed on a pulpotomy site.

• Menstrual and reproductive disorder.

• Eye , ear and nose irritation.

• Asthamatic bronchitis

• Dermatitis, rhinitis, wheezing

• Pharyngitis, chronic cough

• Shortness of breath

• Sexual dysfunction

• Possible cancer.

Electrosurgical Pulpotomy

• The rationale of this technique is the tissue of thecoronal pulp is removed during pulpal amputation, alayer of coagulation necrosis carried by the electrosurgery application provides a barrier between healthyradicular tissue and any base material placed in thepulp chamber.

• The odontoblasts are stimulated to form a denimbridge and the tooth is maintained in the arch withvital radicular tissue until it exfoliates.

ADVANTAGES:

•Quick

•Self limiting

•Hemostasis

•Good visibility

•No systemic effects

DISADVANTAGES:

•Heat leads to tissue destruction

•Persistent inflammation

•Root resorption

Electrosurgical Pulpotomy

• Step1: Local anesthesia and isolation with a rubber dam

• Step2 :Pulp chamber opened

• Step 3 : Coronal pulp removed

• Step 4: Radicular pulp amputated

• Step 5 : Pulp hemostasis obtained

• Step 6 : Electrosurgical current applied for 2 - 5sec to pulp stump

• Step 7 : Calcium hydroxide paste placed

• Step 8: Light-cured glass ionomer cement seal obtained

• Step 9: Stainless steel crown .

Histological Findings Of Electrosurgical Pulpotomy

• The study done by Sheller B et al on eleven human caries –freedeciduous cuspid teeth showed following histological features

• One Hour Posttreatment

• Teeth were free of acute inflammation. Mild signs of chronicinflammation were restricted to the coronal third of theradicular pulp. Slight fibrosis was observed in the coronal thirdof the teeth.

Six Days Posttreatment

• Histological evaluation revealed acute inflammatory cells limited to theapical third of the radicular pulp, diffuse edema and necrosis replacing theentire pulp tissue, and external resorption involving the apical and middlethirds of the roots.

Thirteen Days Posttreatment

• Acute inflammatory cells were observed in the apical area and there wasexternal resorption of the apical third of the root.

• Edema, chronic inflammatory cells and localized necrosis involvingapical third .Pulpal calcifications were located in the coronal third of theradicular pulp.

• Apparently unaffected vital tissue may be present in the middle and apicalthirds of the pulp. Secondary dentin deposits were located on the canalwalls in the coronal portion of the radicular pulp.

Seventeen Days Posttreatment

• There will be acute and chronic inflammatory cells present along withedema restricted to the coronal third of the pulp. Necrosis waslocalized to the pulp to the pulp chamber interface.

• Secondary dentin deposits on the canal walls in the coronal and middlethird of the root.

Seventy Days Posttreatment

• The teeth showed small number of acute and chronic inflammatory cellsrestricted to the coronal third of the radicular pulp.

• Secondary dentin deposits were present both as canal wall deposits andpulpal stones.

One Hundred Days Posttreatment • Chronic inflammatory infiltrate and edema can be present in the tissue

sub adjacent to pulp amputation. • Secondary dentin formation includes canal deposits

Laser Pulpotomy

• Patient selection criteria

• Clinically

• Primary teeth required a pulpotomy because of pulpal exposure to caries.

• Teeth have normal mobility.

• No tenderness to percussion.

• No swelling or fistulation

• Radiographically

• Teeth presented a carious pulpal exposure without furcation or periapical pathology.

• Root resorption was confirmed to less than one third of the root.

Laser pulpotomy…

Ebimara (1985) Nd:YAG laser

CO2 LASERS:

PROCEDURE ;

• L.A & isolation

• Excavation & hemorrhage control

• Complete hemostasis by exposure

to Nd:YAG laser at 2 W,20 Hz (100 mJ)

• IRM & composite

• Stainless steel crown

Histological Findings Of Laser Pulpotomy

• In 1996, Wlkerson et al evaluated the clinical,radiographic and histologic effects of argon laser on vitalpulpotomy of swine teeth. The results showed that

• All soft tissue remained normal

• All teeth exhibited normal mobility

• Reparative dentine formation was noted histologically

• They concluded that use of argon laser for pulpotomy didnot appear to be detrimental to pulp tissues. These studiesled to the use of Nd: YAG laser for pulpotomy in primaryteeth.

Jeng –fen liu (1999)

• Treated 23 teeth – 6 months evaluation, one teeth showed internal resorption

Peschek et al 2002 -- CO2 laser

Wildersmith 1997 and Day 1998 found CO2 laser pulpotomy to be very successful

Calcium hydroxide pulpotomy

• Most favored in 1940s and mid 1950s

• Teuscher & Zander (1938)- termed vital technique; demonstrated necrosis of pulp lying close to Ca(OH)2 and secondary dentin formation

3 distinct zones :• Coagulation necrosis• Deep staining basophilic areas of varied

osteodentin • Relatively normal pulp( slightly hyperemic)

Indications

• Young permanent tooth owing to its less cellular activity than the primary

• Mechanical, Carious, Traumatic exposure with incomplete apical closure

Contraindications

• Not recommended for primary teeth -Diffuse inflammation -Internal resorption– Tronstad1988

Procedure

• Anesthesia, isolation• Caries removed with out pulp exposure• Deroofing the pulp chamber• Coronal pulp amputation• Control of haemorrhage• Ca(OH)2 placed over the orifice and dried with

cotton pellet• Quick setting ZOE cement placed over it• Stainless steel crown (post. teeth)• Restoration / composite (ant. teeth)

Calcium Hydroxide Pulpotomy Outcomes In Primary Teeth

• Internal resorption may result from over stimulation of the primarypulp by the highly alkaline calcium hydroxide. This alkalineinduced over stimulation could cause metaplasia within the pulptissue, leading to the formation of odontoclasts. In addition,undetected microleakage could allow large number of bacterial tooverwhelm the pulp and nullify the beneficial effects of calciumhydroxide.

• Via, in a 2 year study of calcium hydroxide pulpotomies in primaryteeth, had only a 31% success.

• Law reported only a 49% success in a 1 year study. In year study,in all investigations, failure rates with hydroxide in pulpotomizedprimary molars.

Histological Findings Of Calcium Hydroxide

Pulpotomy –By Siu et al

Short Term Study (Seven Days)

• For seven days in comparison between Life, Dycal, Nu-Cap and calcium hydroxide in 28 teeth. Itshowed that the calcium hydroxide saline pastecauses a greater inflammatory response withinthe pulp, and also resulted in wide zone ofmummification. This finding may be associatedwith greater alkalinity of the calcium hydroxidepaste.

LONG TERM STUDY (sixty-three days)

• Here, the trend showed increased inflammation with the calciumhydroxide- saline paste was noted.

• Specific instances of high inflammatory reaction were associatedwith deep maceration of the pulp during the initial preparation andinclusion of dentinal chips and medicaments.

• All medicaments stimulated dentinal bridges , there were importantdifferences in quality and position. The calcium hydroxide – salinepaste consistently formed thick bridges, but they occurred deepwithin the pulp at the junction of the mummified zone and thenormal pulp tissue.

• Excessive and deep bridge formation may result in the areas ofnecrotic pulpal tissue, secondary to vascular constriction.

GlutaraldehydeAdvantages

1) Reaction to pulp is irreversible.2)Molecules of glutaraldehyde do not diffuse out of

apical foramen.3)It fixes tissue instantly and excess solution is

unnecessary.4)It is not known to be cytotoxic, mutagenic or

carcinogenic.5) It has no systemic toxic effects.

• Disadvantages

– Short shelf life.

– It has to be freshly prepared.

– Buffered solution has to be refrigerated.

Properties Of Glutaraldehyde (Ranly1982,Kennedy1986)

• Superior fixation with relatively little

immunogenecity

• Mild effects on pulp tissue

• Lesser Systemic Distribution

• Positive clinical results (Garcia

godoy1986, Fuks et al 1986)

Histologic Features

• Less damage apically and less necrosis

• Less clearly demarcated zones within radiculartissue.

• No evidence of in growth of granulation tissue.

• Less intense dystrophic calcification limited tocoronal portion of canal

• Fibroblastic proliferation observedimmediately below Glutaraldehyde fixed tissuein coronal 3rd indicating repair replacement.

Glutaradehyde Vs Formocresol

• Ranly and associates recommened 4% bufferedglutaraldehyde with a 4 minute application time or 8% for 2minutes. Glutaraldehyde seems to be superior toformaldehyde for pulp canal therapy in many respects.

• Most formaldehyde reactions are reversible , glutaraldehydereactions are not as they are bound to protein tissue.

• Formaldehyde is a small molecule and pentrates theperiapical end easily .Glutaraldehyde being a large moleculedoes not penetrate into the periapical tissue. Less pulpalirritation is seen because of less apical diffusion.

• Formaldehyde fixes tissue with a long reaction time and anexcess of solution , glutaraldehyde fixes tissueinstantaneously and an excess of solution is not necessary.

• Zone of inhibition is more restricted followingits application.

• Formocresol caused lysis of PMN and at highconcentration but activation of PMN adherenceat low concentration.

• In contrast glutaraldehyde did not producePMN lysis at high concentration, nor did itcause activation of PMN adherence at lowconcentration.

• Ranley has mentioned that it is hard to agree thattwo drugs are similarly toxic at equimolarconcentrations.

• Gluteraldehyde excels over formocresol relative toCytotoxicity because it is an effective fixative at alesser concentration and it does not havecompound cresol, a repulsive ,caustic chemicalthat ravages the tissues.

• The effect of glutaraldehyde from availablestudies appears to be gentle and, localized.

Laser Pulpotomy

• Patient selection criteria

• Clinically

• Primary teeth required a pulpotomy because of pulpal exposure to caries.

• Teeth have normal mobility.

• No tenderness to percussion.

• No swelling or fistulation

• Radiographically

• Teeth presented a carious pulpal exposure without furcation or periapical pathology.

• Root resorption was confirmed to less than one third of the root.

Laser pulpotomy…

Ebimara (1985) Nd:YAG laser

CO2 LASERS:

PROCEDURE ;

• L.A & isolation

• Excavation & hemorrhage control

• Complete hemostasis by exposure

to Nd:YAG laser at 2 W,20 Hz (100 mJ)

• IRM & composite

• Stainless steel crown

Histological Findings Of Laser Pulpotomy

• In 1996, Wlkerson et al evaluated the clinical,radiographic and histologic effects of argon laser on vitalpulpotomy of swine teeth. The results showed that

• All soft tissue remained normal

• All teeth exhibited normal mobility

• Reparative dentine formation was noted histologically

• They concluded that use of argon laser for pulpotomy didnot appear to be detrimental to pulp tissues. These studiesled to the use of Nd: YAG laser for pulpotomy in primaryteeth.

Jeng –fen liu (1999)

• Treated 23 teeth – 6 months evaluation, one teeth showed internal resorption

Peschek et al 2002 -- CO2 laser

Wildersmith 1997 and Day 1998 found CO2 laser pulpotomy to be very successful

Calcium hydroxide pulpotomy

• Most favored in 1940s and mid 1950s

• Teuscher & Zander (1938)- termed vital technique; demonstrated necrosis of pulp lying close to Ca(OH)2 and secondary dentin formation

3 distinct zones :• Coagulation necrosis• Deep staining basophilic areas of varied

osteodentin • Relatively normal pulp( slightly hyperemic)

Indications

• Young permanent tooth owing to its less cellular activity than the primary

• Mechanical, Carious, Traumatic exposure with incomplete apical closure

Contraindications

• Not recommended for primary teeth -Diffuse inflammation -Internal resorption– Tronstad1988

Procedure

• Anesthesia, isolation• Caries removed with out pulp exposure• Deroofing the pulp chamber• Coronal pulp amputation• Control of haemorrhage• Ca(OH)2 placed over the orifice and dried with

cotton pellet• Quick setting ZOE cement placed over it• Stainless steel crown (post. teeth)• Restoration / composite (ant. teeth)

Calcium Hydroxide Pulpotomy Outcomes In Primary Teeth

• Internal resorption may result from over stimulation of the primarypulp by the highly alkaline calcium hydroxide. This alkalineinduced over stimulation could cause metaplasia within the pulptissue, leading to the formation of odontoclasts. In addition,undetected microleakage could allow large number of bacterial tooverwhelm the pulp and nullify the beneficial effects of calciumhydroxide.

• Via, in a 2 year study of calcium hydroxide pulpotomies in primaryteeth, had only a 31% success.

• Law reported only a 49% success in a 1 year study. In year study,in all investigations, failure rates with hydroxide in pulpotomizedprimary molars.

Histological Findings Of Calcium Hydroxide

Pulpotomy –By Siu et al

Short Term Study (Seven Days)

• For seven days in comparison between Life, Dycal, Nu-Cap and calcium hydroxide in 28 teeth. Itshowed that the calcium hydroxide saline pastecauses a greater inflammatory response withinthe pulp, and also resulted in wide zone ofmummification. This finding may be associatedwith greater alkalinity of the calcium hydroxidepaste.

LONG TERM STUDY (sixty-three days)

• Here, the trend showed increased inflammation with the calciumhydroxide- saline paste was noted.

• Specific instances of high inflammatory reaction were associatedwith deep maceration of the pulp during the initial preparation andinclusion of dentinal chips and medicaments.

• All medicaments stimulated dentinal bridges , there were importantdifferences in quality and position. The calcium hydroxide – salinepaste consistently formed thick bridges, but they occurred deepwithin the pulp at the junction of the mummified zone and thenormal pulp tissue.

• Excessive and deep bridge formation may result in the areas ofnecrotic pulpal tissue, secondary to vascular constriction.

GlutaraldehydeAdvantages

1) Reaction to pulp is irreversible.2)Molecules of glutaraldehyde do not diffuse out of

apical foramen.3)It fixes tissue instantly and excess solution is

unnecessary.4)It is not known to be cytotoxic, mutagenic or

carcinogenic.5) It has no systemic toxic effects.

• Disadvantages

– Short shelf life.

– It has to be freshly prepared.

– Buffered solution has to be refrigerated.

Properties Of Glutaraldehyde (Ranly1982,Kennedy1986)

• Superior fixation with relatively little

immunogenecity

• Mild effects on pulp tissue

• Lesser Systemic Distribution

• Positive clinical results (Garcia

godoy1986, Fuks et al 1986)

Histologic Features

• Less damage apically and less necrosis

• Less clearly demarcated zones within radiculartissue.

• No evidence of in growth of granulation tissue.

• Less intense dystrophic calcification limited tocoronal portion of canal

• Fibroblastic proliferation observedimmediately below Glutaraldehyde fixed tissuein coronal 3rd indicating repair replacement.

Glutaradehyde Vs Formocresol

• Ranly and associates recommened 4% bufferedglutaraldehyde with a 4 minute application time or 8% for 2minutes. Glutaraldehyde seems to be superior toformaldehyde for pulp canal therapy in many respects.

• Most formaldehyde reactions are reversible , glutaraldehydereactions are not as they are bound to protein tissue.

• Formaldehyde is a small molecule and pentrates theperiapical end easily .Glutaraldehyde being a large moleculedoes not penetrate into the periapical tissue. Less pulpalirritation is seen because of less apical diffusion.

• Formaldehyde fixes tissue with a long reaction time and anexcess of solution , glutaraldehyde fixes tissueinstantaneously and an excess of solution is not necessary.

• Zone of inhibition is more restricted followingits application.

• Formocresol caused lysis of PMN and at highconcentration but activation of PMN adherenceat low concentration.

• In contrast glutaraldehyde did not producePMN lysis at high concentration, nor did itcause activation of PMN adherence at lowconcentration.

• Ranley has mentioned that it is hard to agree thattwo drugs are similarly toxic at equimolarconcentrations.

• Gluteraldehyde excels over formocresol relative toCytotoxicity because it is an effective fixative at alesser concentration and it does not havecompound cresol, a repulsive ,caustic chemicalthat ravages the tissues.

• The effect of glutaraldehyde from availablestudies appears to be gentle and, localized.

Ferric Sulfate

• Monsels Solution [20% ferric subsulfate]

• Strong styptic,1st used in military hospital in Bordeaux ,France 1857 [Larson 1988]

• It was proposed as a Pulpotomy medicament for vital primary teeth.

• Feraculum Solution 1% [prabhu etal 1997]

• Advantage Over FC15 sec for manipulation compared to 5 min FC

Histological Findings Of Ferric Sulphate Pulpotomy

• Landau and Johnsen in which ferric sulphate was usedto control hemorrhage before calcium hydroxideplacement.

• Vital pulpal tissue was found at the apical third of allteeth with ferric sulphate after 60 days, compared tofour of seven teeth in the sterile water calciumhydroxide control group.

• However, the sample sizes were small and the recallperiod was short. Although, the ferric sulphatetechnique appeared successful histologically, the longterm effect of this drug on the teeth and rest of thebody was not addressed.

Advantages Of Ferric Sulfate Over Formocresol

• According to Bimstein - replacement of Formocresol withferric sulfate in general anesthesia cases, where severalpuipotomies have to be done, can reduce systemic toxiceffects caused by Formocresol.

• Manipulation time of 15 seconds for Ferric suifate isadvantageous when compared to 5 min for formocresol,with same success rates. Systemic distribution of Ferricsuifate is unknown, because the clot avoids distributionLemon Additional long-term studies with increased samplesizes should be conducted before ferric suifate can berecommended as a substitute for the "gold standard"formocresol technique.

• Burnett and Walker conducted a retrospective radiographic surveyin order to compare the success rates of ferric sulfate pulpotomiesversus formocresol pulpotomies in a Native American population inArizona. The results of comparison shows over 3 times the clinicalfailure rate in Ferric sulfate pulpotomies compared to Formocresolpulpotomies long term success in best with Formocresol and worstwith a combination of formocresol and Ferric sulfate technique.Results also conformed that radiographic failures are significantlyhigher than clinical failures.

• Ibricevic H, AI-Jame Q compared the effects of ferric sulphate tothat of full strength of formocresol as pulpotomy agents in primaryteeth and after long term follow up concluded that ferric sulphateshowed similar clinical and radiographic success rate asformocresol.

Bone Morphegenic Protien

• In 1938 Levander reported that there must be somestimulating agent which originated from bone and possiblya substance which was soluble in lymph tissue.

• Urist referred the bone inducing substance to “BoneMorphogenic Proteins” which were originally identified bytheir presence in bone inductive extracts of demineralizedbone in 1965.

• Inducing substance i.e. Bone Morphorgenic Protein actingupon a responding cell i.e. - undifferentiated mesenchymalcell to become progenitor cell. Levander thus concludedthat there is an extractable substance from bone which isable to activate mesenchymal cells to form tissue.

• Due to their amino acid sequences BMP-2 through BMP-9 areclassified as belonging to the Transforming Growth Factor-(TGF-B) superfamily.

• Bone Morphogenic proteins are divided into 3 groups

• BMP –2 and BMP-4 form one group having 92% identicalamino acid.

• BMP –5 through BMP-9 form a second group having 82%identical amino acid.These two groups have 59%homologywith one another and only 45%homology with BMP-3.

• BMP –7 and BMP-8 are also known as osteogenic protein OP-1 AND OP-2 respectively.

Sources Of Bone Morphogenic Protiens

• BMP exists in the bone matrix (Sampath and Reddi 1983, Muthukumaran et al 1985)

• Osteosarcoma tissue (Takaaka etal 1980)

• In dentin matrix (Butler et al 1977, Conover and Urist 1979)

• In wound tissue after tooth extraction (Bessho et al 1990).

Carrier For Bone Morphogenic Proteins

For the delivery ideally, the carrier for Bone

Morphogenic Protein should be,

-Non collagenous

- Immunogenically inert

- Osteocoiiductive

- Bioabsorbable

Factors influencing the inductive process of

BMP

• Timing of the response (considering both the exposure timerequired as well as the time the inducer is capable ofinducing.)

• Location or proximity of competent cells able to respond.

• Concentration.

• In case of Vital Pulp Therapy we have inducing substance(BMP) acting upon a responding cell (an undifferentiatedmesenchymal cell) to become an osteoprogenitor cellcapable of forming reparative dentin.

• Dental pulp consists of several types of cell includingodontoblast, fibroblasts and undifferentiated mesenchymalcells. Pulpal fibroblast can be regarded as odontoprogenitorcells.

Lyophilized Freeze Dried Platelet Derived

Preperation

• Platelet derived growth factor ,insulin growth factorderived from platelet have generated considerableintreast in the past.these compounds act as signalingproteins that could be directly involved in the regulationof cell proliferation,migration and extra cellular matrixproduction in the dental pulp.

• These proteins have been extensively used in oral andmaxillofacial reconstruction adjunctive proceduresrelated to the placement of osseo integrated implant inhumans and periodontal regeneration.animal and humaninvivo and invitro studies have shown that these proteinsstimulates differentiated cell of the pulp to diffrenciateinto odontoblast to deposit a layer of dentin.

• Damle and R. R. Kalaskan et al Compared theefficiency of lyophilized freeze dried plateletderived with calcium hydroxide as pulpotomyagents in primary molars. It was found thatsuccess rate of lyophilized freeze dried plateletderived pulpotomy proved to be moreefficient.

Enamel Matrix Derivatives

• Syngcuk Kim et al in 2004 conducted a study onenamel matrix derivative induced reparative dentinformation in a pulpotomy model in pig incisors. Thefindings demonstrated that enamel matrix moleculeshave the capacity to induce rapid pulpal wound healingin pulpotomized teeth, and suggest that the longevityand continued presence of enamel matrixmaromolecules at the application site can be utilized tostimulate growth and repair of dentin over a periodconsistent with a favorable treatment outcome.

PULPOTOMY IN PRIMARY MOLARS USING FORMOCRESOL, FERRIC

SULFATE AND MINERAL TRIOXIDE AGGREGATE

Tajik et al Journal of Dentistry (2006; Vol:3, No.1)

ENAMEL MATRIX DERIVATIVE

Causes bio induction of dentin formation

Method:

Success rate:

Clinical: 90%

Radiographic: 60%

JOE 2008, 34:3 Jumana Sabbarani

MTA vs FC

Ped dent 2005 27:2 ; 145

MTA FC

Success rate: 97% 83%

Pulp canal obliteration: 58% 52%

Reasons for failure of pulpotomy therapy

• Erroneous diagnosis of a chronically inflamed radicular pulp as non-inflame and non-infected.

• The irritating effect of eugenol as a component of the pulp spacefilling material.

• Attempt to preserve a tooth with a deep proximal carious lesion acondition leading to leakage due to incomplete coverage.

• Signs of a failure can be seen on radiographic pathologic signs inpulp canal obliteration (sometime termed “cacific metamorphosis”),which can be seen in root canal of pulpotomized primary molars. Inpresence, however is not considered as a failure.

CONCLUSION• No area of treatment in pediatric dentistry has been more

controversial than pulp therapy. In particular, the vitalpulpotomy procedure has been a topic of debate for decades.

• Pulpotomy therapy for the primary dentition has developed along three lines: devitalization, preservation, andregeneration.

• Devitalization, where the intent is to destroy vital tissue, istypified by formocresol and electrocautery.

• Preservation, the retention of maximum vital tissue with noinduction of reparative dentin, is exemplified byglutaraldehyde and ferric sulfate treatment.

• Regeneration, the stimulation of a dentin bridge, has longbeen associated with calcium hydroxide.

.

• Of the three categories, regeneration is expected todevelop the most rapidly in the coming years.Advancesin the field of bone morphogenetic protein(BMP) have opened new vistas in pulp therapy.Human BMPs with dentinogenic properties arebecoming available through recombinant technology.

• We are now entering an era of pulpotomy therapywith healing as the guiding principle.

Thank U!