Pulpotomy Pediatric Prevention Diagnosis Treatment Planning

2010 National Primary
Oral Health Conference

October 24-27
Gaylord Palm, Orlando, Florida
Pulpotomy treatment for

primary teeth
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
Preservation of the primary teeth until

their time of exfoliation is required to:
a. Maintain arch length,

masticatory function and
esthetics.


esthetics.


esthetics.
b. Eliminate pain, inflammation
and infection.


esthetics.
b. Eliminate pain, inflammation
and infection.
c. Prevent any additional pain or
damage to the oral tissues.
Despite all the

prevention
strategies,
childhood caries
is still a fact that
we confront
every day in the
clinic.
The retention of pulpally

involved primary teeth
until the time of normal
exfoliation remains to be
a challenge.
Primary teeth with
cariously exposed vital
pulps should be treated
with pulp therapies that
allow for the normal
exfoliation process.
The retention of pulpally

involved primary teeth
until the time of normal
exfoliation remains to be
a challenge.
Primary teeth with
cariously exposed vital
pulps should be treated
with pulp therapies that
allow for the normal
exfoliation process.
Pulpotomy treatment
for primary teeth
Topics
Introduction
Definition of pulpotomy
Surgical excision of a vital tooth
pulp.
Surgical removal of a portion of
the dental pulp (levels may vary).
Amputation of the coronal portion
of the pulp, and treatment of the
remaining radicular portion in
order to preserve the vitality of
the remaining pulp tissue.
Rationale of pulpotomy
Pulps with a carious
exposure show a
very limited potential
for pulp recovery, as
the result of
bacterial infection of
the pulp.
Therefore, the infected pulp (coronal
or complete) needs to be removed.
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.
After the pulpotomy is
performed the remaining
radicular pulp may be:
1. Rendered inert
by using
formocresol
that is
bactericidal and
fixes the pulp
tissue.
2. Preserved trough
minimal
inflammatory
insult by using an
haemostatic
agent / laser /
elecrosurgery.
3. Encouraged to
form a dentin
bridge using
calcium hydroxide
or mineral trioxide
aggregate (MTA).
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.
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 for pulpotomy

a. Pulp exposure
caused by
caries: small
pulp exposure.
b. Coronal pulp is
still vital.
c. Radicular pulp is
considered to be
normal.
Contraindications for pulpotomy
Preoperative symptoms.
Spontaneous pain
may be the result of
food impaction
Swelling,
spontaneous pain,
etc.
Positive percussion test.

The result of behavior
problems and/or
food impaction.
Tooth restorability.
Proximity of exfoliation, <2/3

of root length. (?)
Irreversible pulp damage.
Irreversible pulp damage.
Pulpotomy treatment
for primary teeth
Topics
Pulpotomy: materials / techniques
What should be
the
characteristics
of an ideal
pulpotomy
material/
technique?

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.

The ideal pulpotomy technique / dressing material
should be:
harmless to the pulp

and surrounding
structures and
promotes healing
(biological).
compatible with the
normal process of root
resorption.
not expensive.
Calcium hydroxide.
Electrosurgery.
Laser.
Glutaraldehyde.
Collagen.
Mineral trioxide aggregate (MTA).
Formocresol.
Diluted formocresol.
Ferric sulfate.
Calcium hydroxide.
Electrosurgery.
Laser.
Glutaraldehyde.
Collagen.
Formocresol.
Ferric sulfate.
Pulpotomy: calcium hydroxide

Rationale
The use of calcium

hydroxide as a pulp
dressing material after
pulpotomy in primary
teeth is expected to
facilitate the formation of
a dentine bridge
(barrier) and promote
the healing of the
radicular pulp tissue.
Pulpotomy: calcium hydroxide

Radiographic study,103 teeth
Success rate of 31%. Among the
unsuccessful teeth, 69% showed evidence of
internal resorption.
The high failure rate in calcium hydroxide

pulpotomies can be attributed to:
Calcium hydroxide has no beneficial
effect on the inflamed pulp.
The creation of an extrapulpal blood cloth.
Via W. Evaluation of deciduous molars treated by pulpotomy andcalcium hydroxide. J Oral
Surg 3:171, 1974.
Calcium hydroxide.
Electrosurgery.
Laser.
Glutaraldehyde.
Collagen.
Formocresol.
Ferric sulfate.
Pulpotomy: electrosurgery
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
Rationale
A layer of coagulation necrosis that is
caused by the electrosurgery
application, provides a barrier between
healthy radicular tissue and any base
material placed in the pulp chamber.
The odontoblasts are stimulated to
form a dentin bridge and the tooth is
maintained in the arch with vital
radicular tissue until it exfoliates.
Sheller B. Electrosurgical pulpotomy: a pilot study in humans.
Journal of endodontics 13:69-76,1987
Requires the purchase of special

equipment; an electrosurgery dental
electrode.
$ 1000.00
Calcium hydroxide.
Electrosurgery.
Laser.
Glutaraldehyde.
Collagen.
Formocresol.
Ferric sulfate.
Pulpotomy: laser
Rationale
Non-pharmaceutical technique.
It creates a superficial zone of
coagulation necrosis that
remains compatible with the
underlying tissue.
pulps retain their vitality and
capability of normal pulp
healing.
Pulpotomy: laser
Calcium hydroxide.
Electrosurgery.
Laser.
Glutaraldehyde.
Collagen.
Formocresol.
Ferric sulfate.
Pulpotomy: glutaraldehyde
Rationale.
Has been suggested as an
alternative to formocresol as
a pulpotomy agent , based on
its superior fixative
properties, low antigenicity,
and low toxicity.
high molecular weight that

limits its tissue penetration.
has a self-limiting penetration,
hence, reduces the extent of
inflammatory response.
superficial fixation with very
little underlying inflammation.
In a 2% solution destroys fungi,

viruses, and bacteria.
It is considered to be better than
formocresol since:
GA does not diffuse trough the
apical foramen.
GA does not penetrate the
periapical tissues as
formocresol.
A normal pulp is seen below

glutaraldehyde pulps,
whereas below formocresol
pulps there is inflammation, or
mummification.
However, the material/technique was
not well accepted by the pediatric
dentists; may be since it is still an
aldehyde (similar to formocresol).
Calcium hydroxide.
Electrosurgery.
Laser.
Glutaraldehyde.
Collagen.
Formocresol.
Ferric sulfate.
Pulpotomy materials / collagen
Rationale
Biological non pharmacological material
that may induce tissue healing.
Biological mineral formation initiates
within collagen fibers
Collagen gels may provide an appropriate
scaffolding for tissue formation.
Substantial tissue healing with an acidsoluble 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.
Formocresol.
Ferric sulfate.
Pulpotomy: mineral trioxide aggregate

Rationale
Prevents microleakage.
Biocompatible.
Promotes regeneration of
original tissues when it is
placed in contact with the
dental pulp or periradicular
tissues.

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.
$330.00 to 425.00
Manf#: 1124-47
UPC#: 039645112441
Manf: QUIKRETE CO.
PORTLAND CEMENT 47LB
Retail Price: $10.55
Regular Price: $9.59
Checkout Price: $8.63
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.
Formocresol.
Ferric sulfate.
Pulpotomy: formocresol (full strength or diluted)
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.
?????????????????
Calcium hydroxide.
Electrosurgery.
Laser.
Glutaraldehyde.
Collagen.
Formocresol.
Ferric sulfate.
Pulpotomy: ferric sulfate

Rationale
Is a nonaldehyde agent that produces
haemostasis at pulp stumps by
chemically sealing blood vessels.
The haemostasis takes place by

agglutination of blood protein, without
the presence of a blood clot, which
suggested that preventing clot formation
might minimize the chances for chronic
inflammation.
Rationale
Induces favorable histological
results in the form of secondary
dentin and bridging.
Retention of maximum vital
tissue and virtual conservation
of the radicular pulp without
induction of reparative dentin.
Comparisons
Comparisons
Laser (n=68): 97 % and 94.1 % clinical and

radiographic success respectively, follow
up for 6 to 64 months.
Formocresol (n=69): 85.5and 78.3% clinical
and radiographic success respectively,
follow up for 9 to 66 months.
Liu J. Effect of ND:YAG laser pulpotomy on human primary
molars. J Endod 2006;32:404407.
Comparisons
Currently available evidence

suggests MTA compared to
FC, FS and CH resulted in
significantly higher clinical
and radiographic success.
Ng et al. Mineral trioxide aggregate as a pulpotomy medicament: an
evidence based assessment. Eur Arch Paediatr Dent 9:58-3, 2008.
Comparisons
MTA induces less

undesirable responses
and may be 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
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.

$330.00 to 425.00
Manf#: 1124-47
UPC#: 039645112441
Manf: QUIKRETE CO.
PORTLAND CEMENT 47LB
Retail Price: $10.55
Regular Price: $9.59
Checkout Price: $8.63
Portland cement may become the material

of choice for pulpotomies in primary teeth.
Comparisons
Success %
Electrosurgery
Formocresol
Clinical
Radiographic
96%
100%
84%
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
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
Success %
Ferric sulfate
Formocresol
Clinical
Radiographic
96.4%
97.5%
92.0%
94.6%
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.
Pulpotomy treatment
for primary teeth
Topics
Technique: caries removal

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.

c. If a small carious pulp exposure is
disclosed, evaluate the pulp condition, and
perform a complete coronal pulpotomy,
complete caries removal.

Judge the condition of the
exposed pulp based on the pulp
tissue color, hemorrhage (none,
moderate, profuse).

If the pulp color is vivid red, the
bleeding is moderate, proceed
with the pulpotomy.

If the pulp color is dark, or there is
no bleeding, or profuse bleeding, a
pulpotomy is contraindicated and
a pulpectomy or extraction is
required.
Technique: pulpotomy
1.Open a wide access to the pulp
chamber with high-sped.
2. Judge the pulp condition based
on the pulp tissue color,
hemorrhage (none, moderate,
profuse).
3. Remove the coronal pulp tissue
with high speed, low speed or a
sharp large spoon excavator.
4. Observe the pulp stumps and judge
the condition of the radicular pulp
(color, hemorrhage).
5. Obtain haemostasis (cotton pellet).
6. Place the pulp dressing material of
your choice and evaluate the pulp
stumps (no more bleeeding).
7. Fill the pulp chamber with IRM.
8. Restore the tooth (preferably with a crown)
1. After complete removal of the caries,
open a wide access to the pulp chamber
with high-sped.
with high-sped.
with high-sped.
2. Judge the pulp condition based
on the pulp tissue color,
hemorrhage (none, moderate,
profuse).
3.The technique for removal of the
coronal pulp tissue is the same
for every material you decide to
use as a pulp dressing material.
You may use a sharp excavator,
slow speed with a large round
bur, or high speed with a 330
tungsten bur.
Removing the coronal pulp

using a sharp excavator

Using slow speed large round bur

Using a 330 high speed bur
Place a cotton pellet to attain hemostasis
Evaluate hemostasis
No bleeding
Unstoppable 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.
Calcium hydroxide
Formocresol.
Glutaraldehyde.
Ferric sulfate.
Mineral trioxide aggregate.
Electrosurgery.
Laser.
Collagen.
Calcium hydroxide
Formocresol.
Glutaraldehyde.
Ferric sulfate.
Electrosurgery.
Laser.
Collagen.
Pulpotomy materials / formocresol

Full strength or diluted
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.
Glutaraldehyde.
Ferric sulfate.
Electrosurgery.
Laser.
Collagen.
Ferric sulfate
1. Control hemorrhage with
cotton pellets.
2. Apply (rub) FS to pulp
stumps for 15 seconds.
3. Rinse with water.
4. Evaluate the pulp stumps.
Apply FS to pulp stumps
for 15 seconds.
Ferric sulfate
3. Rinse with water.
4. Evaluate the pulp stumps.
8. Restore the tooth (preferably with a
crown)
Pulpotomies
success rates were
79.9% for teeth
restored with a SSC
and 60% for those
restored with
amalgam.
Sonmez et al. Success rate of calcium

hydroxide pulpotomy in primary molars
restored with amalgam and stainless steel
crowns. British Dental Journal 208:e18, 2010.
Pulpotomy treatment
for primary teeth
Topics
Pulpotomy / follow up
Clinical and radiographic.

Gingival and periodonatal health.

Parulis / fistula.

Obliteration.

Interadicular radiolucencies.

Periodontal health.

Internal / external abnormal root
resorption.
Both, ferric sulfate
(22%) and formocresol
(20%) pulpotomies
can lead to internal
resorption
Vargas KG. Radiographic success of ferric sulfate and
formocresol pulpotomies in relation to early exfoliation. Ped
Dent 27:233-7, 2005
Internal resorption self-repair?

Early exfoliation.
Both ferric sulfate (11%)
and formocresol (10%)
pulpotomies can lead to
premature exfoliation of
primary teeth, with the
subsequent need for
orthodontic space
maintenance.
Vargas KG. Radiographic success of ferric sulfate and formocresol
pulpotomies in relation to early exfoliation. Ped Dent 27:233-7, 2005
Pulpotomy treatment
for primary teeth
Topics
Pulpotomy / 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.

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2010 National Primary

Oral Health Conference

Pulpotomy treatment for

Preservation of the primary teeth until

a. Maintain arch length,

Preservation of the primary teeth until

a. Maintain arch length,

Preservation of the primary teeth until

a. Maintain arch length,

Preservation of the primary teeth until

a. Maintain arch length,

Despite all the

The retention of pulpally

The retention of pulpally

Indications for pulpotomy

Contraindications for pulpotomy

Contraindications for pulpotomy

Positive percussion test.

Contraindications for pulpotomy

Contraindications for pulpotomy

Proximity of exfoliation, <2/3

Contraindications for pulpotomy

Irreversible pulp damage.

Contraindications for pulpotomy

Irreversible pulp damage.

Pulpotomy: materials / techniques

Pulpotomy: materials / techniques

Pulpotomy: materials / techniques

harmless to the pulp

Pulpotomy: materials / techniques

Pulpotomy: materials / techniques

Pulpotomy: calcium hydroxide

The use of calcium

Pulpotomy: calcium hydroxide

The high failure rate in calcium hydroxide

Pulpotomy: materials / techniques

Requires the purchase of special

Pulpotomy: materials / techniques

Pulpotomy: materials / techniques

high molecular weight that

In a 2% solution destroys fungi,

A normal pulp is seen below

Pulpotomy: materials / techniques

Pulpotomy materials / collagen

Pulpotomy materials / collagen

Pulpotomy: materials / techniques

Pulpotomy: mineral trioxide aggregate

Pulpotomy: mineral trioxide aggregate

Not been found to

Pulpotomy: mineral trioxide aggregate

MTA is a fine hydrophilic powder developed

Pulpotomy: mineral trioxide aggregate

Pulpotomy: mineral trioxide aggregate

Portland cement may

Pulpotomy: materials / techniques

Pulpotomy: formocresol (full strength or diluted)

Excellent clinical success!

Pulpotomy: formocresol (full strength or diluted)

The rationale of fixation

Pulpotomy: materials / techniques

Pulpotomy: ferric sulfate

The haemostasis takes place by

Pulpotomy: ferric sulfate

Pulpotomy: materials / techniques