Pulpotomy

Presented by: ROSHNI MAURYAFINAL YEAR PGT

Pulpotomy

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 the primary

teeth until normal exfoliation.

• Management of the cariously involved primary tooth where the carious lesion approximates the pulp requires a knowledgeable approach to pulp therapy, and a successful outcome depends on accurate diagnosis of the status of the pulp prior to therapy.

• Preliminary data gathering and interpretation must be focused on determining whether the primary tooth pulp is normal, reversibly inflamed, irreversibly inflamed or necrotic.

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

• If the pulp is determined to be irreversibly inflamed or necrotic, either a pulpectomy or extraction would be 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 medicament that will promote healing and preserve the vitality of the tooth (Finn,1985).

• Pulpotomy is defined as the amputation of vital pulp from the coronal pulp chamber followed by placement of a medicament over the radicular pulp stumps to stimulate repair, fixation or mummification of the remaining vital radicular 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 the tissue.The surgical excision of the infected and inflamed coronal pulp, the vital uninfected pulpal tissue can be left behind and preserved in the root canal.

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

Materials used for this procedure either mummify or fix the tissue or promote 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 young permanent teeth is important for treatment planning.

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

• Eidelman et al and Prophet and Miller have emphasized that no single diagnostic means can be relied on for determining a diagnosis 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 and associated periodontium2. Radiographic examination of a. periradicular and furcation areas b. pulp canals c. periodontal space d. developing succedaneous teeth3. 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 exposures Endodontics : 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 chemically

treated pulp tissue that is inert, sterilized, metabolically suppressed, and incapable of autolysis. This approach involved the original two- sitting formocresol pulpotomy, which resulted in complete devitalization of the radicular pulp.

• Also included were the 5- minute formocresol and 1:5 diluted formocresol techniques, which both result in partial devitalization with persistent chronic inflammation.

Preservation: • This approach involved medicaments and techniques

that provide minimal insult to the orifice tissue and maintain the vitality and normal histologic appearance of the entire radicular pulp.

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

• Nonpharamcotherpeutic techniques in this category include electrosurgical and laser pulpotomy.

Regeneration: • This approach includes pulpotomy agents that have cell-

inductive capacity to either replace lost cells or induces existent cells to differentiate into hard tissue forming elements.

Examples of true cell- inductive agents include:

– Transforming growth factor- (TGF- ) in the form of 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-minute formocresol.

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

• Non –vital Pulpotomy: This technique is carried out when the inflammatory process affecting the coronal pulp extends to the radicular 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) to remove all carious dentin .If possible, remove all carious dentin before exposing the pulp horns

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

• Step 5: Excise the pulpal tissue to the orifices of the root canal. Use a large spoon excavator to remove any remaining pulpal tissue.The pulpal tissue should be amputated to the entrance of the root canals.

• Step 6: After completing the amputation, evaluate the hemorrhage. If the pulpal tissue has been removed completely, hemorrhage should be minimal.A vital pulp with minimal chronic inflammation should achieve hemostasis in 3 to 5 minutes.

• Step 7: Over the exposed pulp stump, place sterile cotton pellet 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 cotton wool, the larger the exposure then the more successful the outcome.

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

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

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

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

Non Vital Pulpotomy (Mortal Pulpotomy)

• Indications

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

• When the pulp is completely non-vital, where there may be an abscess present with or without acute 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, as recommended in the vital pulpotomy technique.

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

• A small pledget of cotton wool dipped in beechwood cresol is then sealed into the cavity with temporary zinc oxide eugenol cement.

• IInd visit:

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

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

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

• Other medcaments like formocresol and camphorated monochlorophenol (Arnold and Rock, 1993) have been equally effective, at the second visit, after one to two weeks an antiseptic paste that is placed over the radicular pulp remnants before restoring the tooth 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 full coverage of the crown with a bonded resin- composite strip crown.

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

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

• During the procedure, an operative diagnosis should be made by assessing the pulpal with regard to the bleeding from the amputation site, including the color, 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 without premedication.

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

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

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

• 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, who

contended that equal parts of formalin and tricresol would react chemically with the intermediate and end products of pulp 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: 5

concentration) of Buckley’s formocresol applied to tissue achieved the desired cellular response.

• The orginal buckley’s formula for formocresol calls for equal parts of formaldehyde and cresol. The 1:5 concentration of this formula is prepared by first thoroughly mixing three parts of glycerin with one part of distilled water, then adding four parts of this diluent to one part of Buckley’s Formocresol and thoroughly mixing again.

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% -3months 83% - 12 months

78% - 24 months 70% - 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 is eosinophilic tissue interpreted as the zone of fixation.

• The next zone is the pale staining amorphous zone with diminished cellular and fiber definition which is the result of lipid dissolving property of cresol. Stagnation necrosis as a consequence of formocresol induced vascular thrombosis.

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

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

• Formocresol seeps in through accessory canals into developing tooth germ and causes enamel defects like hypoplasia and might alter position of underlying permanent tooth (Messler 1980)

• Jerell and Ronk 1982 described arrested development of bicuspid while Grundy and coworkers in 1984 described cyst in primary teeth treated with formaldehyde

Systemic toxicity

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

• The remaining drug bound to tissue predominantly in the kidney and lungs. When administered systemically in large doses, acute toxic effects (e.g., cardiovascular changes, plasma and urinary enzyme changes, histologic evidence of cellular injury to the vital organs) were noted.

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

• With the use of isotope-labeled, 19% formaldehyde, the presence of the drug was demonstrated in the lung, liver, kidney, muscle, serum, urine and carbon dioxide after 5-minute application of pulpotomy sites. The concentrations achieved in the tissues were equivalent to those found after an infusion of 30% of the amount placed in the pulp chamber.

• Pashley and Myers et al (1980) in their study on dogs determined the fate of the C-formaldehyde following an application to pulpotomy sites and confirmed (with their previous finding) that C-formaldehyde containing formocresol was absorbed from pulpotomy sites and appeared in body fluids. They concluded that formocresol is absorbed and distributed rapidly and widely throughout the body within minutes 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 the coronal pulp is removed during pulpal amputation, a layer of coagulation necrosis carried by the electro surgery application provides a barrier between healthy radicular tissue and any base material placed in the pulp chamber.

• The odontoblasts are stimulated to form a denim bridge and the tooth is maintained in the arch with vital 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 –free deciduous cuspid teeth showed following histological features

• One Hour Posttreatment

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

Six Days Posttreatment

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

Thirteen Days Posttreatment • Acute inflammatory cells were observed in the apical area and there was

external resorption of the apical third of the root. • Edema, chronic inflammatory cells and localized necrosis involving apical

third .Pulpal calcifications were located in the coronal third of the radicular pulp.

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

Seventeen Days Posttreatment • There will be acute and chronic inflammatory cells present along with edema

restricted to the coronal third of the pulp. Necrosis was localized to the pulp to the pulp chamber interface.

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

Seventy Days Posttreatment • The teeth showed small number of acute and chronic inflammatory cells

restricted to the coronal third of the radicular pulp. • Secondary dentin deposits were present both as canal wall deposits and pulpal

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• In 1996, Wlkerson et al evaluated the clinical, radiographic

and histologic effects of argon laser on vital pulpotomy 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 did not

appear to be detrimental to pulp tissues. These studies led to the use of Nd: YAG laser for pulpotomy in primary teeth.

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 primary pulp by the highly alkaline calcium hydroxide. This alkaline induced over stimulation could cause metaplasia within the pulp tissue, leading to the formation of odontoclasts. In addition, undetected microleakage could allow large number of bacterial to overwhelm the pulp and nullify the beneficial effects of calcium hydroxide.

• Via, in a 2 year study of calcium hydroxide pulpotomies in primary teeth, 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 pulpotomized primary 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. It showed that the calcium hydroxide saline paste causes a greater inflammatory response within the pulp, and also resulted in wide zone of mummification. This finding may be associated with greater alkalinity of the calcium hydroxide paste.

LONG TERM STUDY (sixty-three days)

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

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

• All medicaments stimulated dentinal bridges , there were important differences in quality and position. The calcium hydroxide – saline paste consistently formed thick bridges, but they occurred deep within the pulp at the junction of the mummified zone and the normal pulp tissue.

• Excessive and deep bridge formation may result in the areas of necrotic 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 radicular

tissue.• No evidence of in growth of granulation tissue.• Less intense dystrophic calcification limited to

coronal portion of canal• Fibroblastic proliferation observed immediately

below Glutaraldehyde fixed tissue in coronal 3rd indicating repair replacement.

Glutaradehyde Vs Formocresol

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

 • Most formaldehyde reactions are reversible , glutaraldehyde reactions

are not as they are bound to protein tissue.• Formaldehyde is a small molecule and pentrates the periapical end

easily .Glutaraldehyde being a large molecule does not penetrate into the periapical tissue. Less pulpal irritation is seen because of less apical diffusion.

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

• Zone of inhibition is more restricted following its application.

• Formocresol caused lysis of PMN and at high concentration but activation of PMN adherence at low concentration.

• In contrast glutaraldehyde did not produce PMN lysis at high concentration, nor did it cause activation of PMN adherence at low concentration.

• Ranley has mentioned that it is hard to agree that two drugs are similarly toxic at equimolar concentrations.

• Gluteraldehyde excels over formocresol relative to Cytotoxicity because it is an effective fixative at a lesser concentration and it does not have compound cresol, a repulsive ,caustic chemical that ravages the tissues.

• The effect of glutaraldehyde from available studies 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 FC 15 sec for manipulation compared to 5 min FC

Histological Findings

• Landau and Johnsen in which ferric sulphate was used to control hemorrhage before calcium hydroxide placement.

• Vital pulpal tissue was found at the apical third of all teeth with ferric sulphate after 60 days, compared to four of seven teeth in the sterile water calcium hydroxide control group.

• However, the sample sizes were small and the recall period was short. Although, the ferric sulphate technique appeared successful histologically, the long term effect of this drug on the teeth and rest of the body was not addressed.

Advantages Of Ferric Sulfate Over Formocresol

• According to Bimstein - replacement of Formocresol with ferric sulfate in general anesthesia cases, where several puipotomies have to be done, can reduce systemic toxic effects caused by Formocresol.

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

• Burnett and Walker conducted a retrospective radiographic survey in order to compare the success rates of ferric sulfate pulpotomies versus formocresol pulpotomies in a Native American population in Arizona. The results of comparison shows over 3 times the clinical failure rate in Ferric sulfate pulpotomies compared to Formocresol pulpotomies long term success in best with Formocresol and worst with a combination of formocresol and Ferric sulfate technique. Results also conformed that radiographic failures are significantly higher than clinical failures.

 • Ibricevic H, AI-Jame Q compared the effects of ferric sulphate to

that of full strength of formocresol as pulpotomy agents in primary teeth and after long term follow up concluded that ferric sulphate showed similar clinical and radiographic success rate as formocresol.

Bone Morphegenic Protien

• In 1938 Levander reported that there must be some stimulating agent which originated from bone and possibly a substance which was soluble in lymph tissue.

• Urist referred the bone inducing substance to “Bone Morphogenic Proteins” which were originally identified by their presence in bone inductive extracts of demineralized bone in 1965.

• Inducing substance i.e. Bone Morphorgenic Protein acting upon a responding cell i.e. - undifferentiated mesenchymal cell to become progenitor cell. Levander thus concluded that there is an extractable substance from bone which is able to activate mesenchymal cells to form tissue.

• Due to their amino acid sequences BMP-2 through BMP-9 are classified 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% identical amino acid.

• BMP –5 through BMP-9 form a second group having 82% identical amino acid.These two groups have 59%homology with 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 time required as well as the time the inducer is capable of inducing.)

• 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 undifferentiated mesenchymal cell) to become an osteoprogenitor cell capable of forming reparative dentin.

• Dental pulp consists of several types of cell including odontoblast, fibroblasts and undifferentiated mesenchymal cells. Pulpal fibroblast can be regarded as odontoprogenitor cells.

Lyophilized Freeze Dried Platelet Derived Preperation

• Platelet derived growth factor ,insulin growth factor derived from platelet have generated considerable intreast in the past.these compounds act as signaling proteins that could be directly involved in the regulation of cell proliferation,migration and extra cellular matrix production in the dental pulp.

• These proteins have been extensively used in oral and maxillofacial reconstruction adjunctive procedures related to the placement of osseo integrated implant in humans and periodontal regeneration.animal and human invivo and invitro studies have shown that these proteins stimulates differentiated cell of the pulp to diffrenciate into odontoblast to deposit a layer of dentin.

• Damle and R. R. Kalaskan et al Compared the efficiency of lyophilized freeze dried platelet derived with calcium hydroxide as pulpotomy agents in primary molars. It was found that success rate of lyophilized freeze dried platelet derived pulpotomy proved to be more efficient.

Enamel Matrix Derivatives

• Syngcuk Kim et al in 2004 conducted a study on enamel matrix derivative induced reparative dentin formation in a pulpotomy model in pig incisors. The findings demonstrated that enamel matrix molecules have the capacity to induce rapid pulpal wound healing in pulpotomized teeth, and suggest that the longevity and continued presence of enamel matrix maromolecules at the application site can be utilized to stimulate growth and repair of dentin over a period consistent with a favorable treatment outcome.

PULPOTOMY IN PRIMARY MOLARS USING FORMOCRESOL, FERRICSULFATE AND MINERAL TRIOXIDE AGGREGATE

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

ENAMEL MATRIX DERIVATIVE

Causes bio induction of dentin formationMethod: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 space filling material.

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

• Signs of a failure can be seen on radiographic pathologic signs in pulp canal obliteration (sometime termed “cacific metamorphosis”), which can be seen in root canal of pulpotomized primary molars. In presence, 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 vital pulpotomy procedure has been a topic of debate for decades.

• Pulpotomy therapy for the primary dentition has developed a long three lines: devitalization, preservation, and regeneration.

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

• Preservation, the retention of maximum vital tissue with no induction of reparative dentin, is exemplified by glutaraldehyde and ferric sulfate treatment.

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

.

• Of the three categories, regeneration is expected to develop 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 are becoming available through recombinant technology.

• We are now entering an era of pulpotomy therapy

with healing as the guiding principle.

Thank U!