OUTLINE

A. The Pulpotomy Technique

Pulp Therapy for Primary Teeth

1- Diagnosis
2- Indications / Contraindications
3- StepStep-byby-step pulpotomy technique
4- Mechanism of action of formocresol
5- Alternatives to formocresol

B. The Pulpectomy Technique

Reporter:

1- Rationale for pulpectomy

2- Indications / Contraindications
3- Root canal filling material
4- Types of pulpectomy techniques
5- Success rates for primary tooth pulpectomies

2004/03/30

Introduction
Preservation of primary teeth in the arch
Management of developing dentition
Nurturing a positive attitude in
children towards dental health

A. The Pulpotomy Technique

Introduction
Use of pulp therapy to conserve carious
primary teeth
Preserve pulp involved primary molar
when missing permanent successor
Prevent possible aberrant habits
Maintain masticatory function
Preserve aesthetics
Future dental attitudes

A pulpotomy is the procedure of

removing coronal part of pulp
tissue, inflamed or infected as
a result of deep caries, &
maintenance of vital radicular
pulp tissue

A1A1- Diagnosis
1/5 dilution of
the original Buckley
Buckleys formocresol

Primary tooth with deep caries

OD (with GIC)
or
Pulpotomy

NISHIKA
Root canal disinfectant

Cresol
40mL
Formalin 40mL
Ethanol 20mL

A1A1- Diagnosis

A1A1- Diagnosis
The reason for this is that
caries in primary teeth
compromises pulp very early on,
with pulp inflammation setting in
even before pulp is exposed

A1A1- Diagnosis
Hobson (1970)
In over 50% of the primary molars
Loss of marginal ridge
irreversible pulp inflammation

A1A1- Diagnosis
Duggal et al (1999)
The need for pulp therapy for
most primary molars where
proximal caries has involved the
marginal ridge
The importance of early
diagnosis of proximal caries with
the use of bitewing radiographs

A1A1- Diagnosis

A1A1- Diagnosis

Proximal caries that involved less than half the

intercuspal distance from buccal to lingual cusp

A1A1- Diagnosis

A1A1- Diagnosis

By the time the caries exposes the pulp, the inflammation is irreversible
irreversible
Direct pulp capping is contraindicated

A2A2- Indications
Large caries with substantial loss (
(1/3 )
of marginal ridge in restorable tooth
Tooth free of radicular pulpitis
At least 2/3 of root remaining
Absence of abscess or fistula
No interinter-radicular bone loss
No evidence of internal resorption
Instances where extraction is C/I

A2A2- Contraindications
An unrestorable tooth
BiBi- or trifurcation involvement
Less than 2/3 of root remaining
Presence of abscess or fistula
Permanent successor close to eruption
Medical contraindications
Heart disease
ImmunoImmuno-compromised children

A3A3- StepStep-byby-step
Step 1: Administer local analgesia with
the use of a topical analgesic

Nerve block

A3A3- StepStep-byby-step
Step 2: Isolate tooth with rubber dam

Buccal infiltration

A3A3- StepStep-byby-step
Step 3: Remove caries &
determine site of pulp exposure

A3A3- StepStep-byby-step
Step 5: Remove coronal pulp with
large excavator or large round bur

A3A3- StepStep-byby-step
Step 4: Remove roof of pulp chamber

A3A3- StepStep-byby-step
Step 6: Apply FC on a pledget of
cotton wool for 4 minutes

A3A3- StepStep-byby-step
Step 7: Remove FC pledget after 4 mins
& check that haemorrhage has stopped

A3A3- StepStep-byby-step
Step 8: Fill pulp chamber with cement

A3A3- StepStep-byby-step
Step 9: Restore tooth with SSC

A3A3- StepStep-byby-step
Step 10: Take a postpost-OP radiograph

A3A3- StepStep-byby-step

A3A3- StepStep-byby-step

FollowFollow-up
Regularly reviewed both clinically &
radiographically 66-monthly
Appearance of rarefaction of bone
in furcation area or
a worsening of bone condition
in furcation
usually signifies failure of the procedure

PrePre-OP

PostPost-OP

3M

12 M

A4A4- Mechanism of action of FC

FC acts through
aldehyde group of formaldehyde,
formaldehyde,
forming bonds with sideside-groups
of amino acids of both bacterial
proteins & remaining pulp tissue
Both bactericidal & devitalizing
agent

A5A5- Alternatives to FC
Concern about possible toxicity of
FC, both locally & systemically
Alternatives
Ferric sulphate [Fe2(SO4)3]
Glutaraldehyde
Calcium hydroxide
Other experimental methods

A5A5- Alternatives to FC
Glutaraldehyde
Introduced by sGravenmade (1975)
Better fixative agent
Toxic properties

A4A4- Mechanism of action of FC

Reported
success rate
of FC
pulpotomy

A5A5- Alternatives to FC
Ferric sulphate [Fe2(SO4)3, 15.5%]
Excellent haemostatic agent
(ferric ionion-protein complex)
As effective as FC
No fixative
fixative effect

A5A5- Alternatives to FC
Calcium hydroxide
Poor (around 60%) success rate
Extensive internal resorption
below amputation

Allergic reactions
Eye irritation

A5A5- Alternatives to FC
Other experimental methods
Electrosurgery
CO2 lasers
Enriched collagen solution

B. The Pulpetomy Technique

B1B1- Rationale for pulpectomy

It is true that some primary teeth
do have a complex root
morphology (with many fine
accessory root cancals),
cancals),
but this does not contraindicate
pulpectomy

B2B2- Indications

Irreversible inflammation
extending to radicular pulp
Primary teeth with necrotic pulps
Evidence of furcation pathology
Presence of an abscess

Gain access to the root canals

Remove
Remove as much dead &
infected material as possible
Fill the root canals with a suitable
material
Maintain primary tooth in a nonnoninfected state

B2B2- Contraindications

Unrestorable crown
Advanced pathological root
resorption
Medical contraindications
Heart disease
ImmunoImmuno-compromised
children

B3B3- Root canal filling material

B3B3- Root canal filling material

Being totally resorbed at the

same rate as the roots
Pure zinc oxide & eugenal mixed
as a slurry
Maisto
Maistos paste
Iodoform paste
Vitapex

B3B3- Root canal filling material

Ca(OH)2-Iodoform Mixture

- Vitapex, Endoflas
- Machida (1983): Ca(OH)2-iodoform mixture to
be a nearly ideal primary tooth filling material
1) easy to apply
2) resorbs at a slightly faster rate
than that of the roots
3) has no toxic effects on the
permanent successor
4) radiopaque

B4B4- Single-visit of pulpectomy

Indications
Presence of inflamed but vital
radicular pulp
An asymptomatic primary tooth
with necrotic pulp tissue without
any associated acute symptoms,
such as cellulitis
Presence of a chronic buccal
lesion without any active
discharge or acute symptoms

3 M later

B4B4- Types of pulpectomy

One-stage / single-visit
pulpectomy
Two-stage / two-visit
pulpedctomy

B4B4- Single-visit of pulpectomy

Step 1: Give local analgesia &

isolate tooth with rubber dam

B4B4- Single-visit of pulpectomy

Step 2: Remove caries &

identify exposure site

B4B4- Single-visit of pulpectomy

Step 4: Take a diagnostic radiograph

with files in the root canals

B4B4- Single-visit of pulpectomy

Step 3: Remove roof of pulp chamber,

& identify opening of root canals

B4B4- Single-visit of pulpectomy

Step 5: Clean out root canals with H files

& remove remnants of pulp tissue
& irrigate canals with saline

Within 11-2 mm
File lightly
Reaming is not advisable
File to no more than size 30

B4B4- Single-visit of pulpectomy

Step 6: Dry root canals with paper points

& place a pledget of FC in pulp chamber
for 4 minutes

B4B4- Single-visit of pulpectomy

Step 7: Select a spiral root canal filler of

appropriate size

B4B4- Single-visit of pulpectomy

Step 8: Mix ZnO & eugenol as a slurry,

B4B4- Single-visit of pulpectomy

Step 9: Fill pulp chamber with cement

& spin it into root canals using

spiral root canal filler

B4B4- Single-visit of pulpectomy

Step 10: Restore the tooth with SSC

B4B4- Single-visit of pulpectomy

Step 11: Take a postpost-op radiograph to

check root filling

B4B4- Singleingle-visit of pulpectomy

B4B4- Singleingle-visit of pulpectomy

FollowFollow-up
Regularly reviewed both clinically &
radiographically 66-monthly

PrePre-OP

PostPost-OP

6 M later

PrePre-OP

3 M later

PostPost-OP

12 M later

10

B4B4- Singleingle-visit of pulpectomy

92/08/21
(F/U 9M)

PrePre-OP

PrePre-OP
91/11/12
(Root canal filling)

6 M later

92/12/29
(F/U 13M)

PostPost-OP

B4B4- Two-visit of pulpectomy

B4B4- Singleingle-visit of pulpectomy

Spiral root filler

Indications
Presence of an acute abscess
with or without associated
cellulitis
Presence of active & persistent
discharge from the root canals

B4B4- Two-visit of pulpectomy

Visit 1: Emergency management of
the acute abscess
Gaining drainage through carious cavity
or puncturing fistula
LA
LA Filed to drain
FC pledget
pledget IRM
Antibiotics: 22-dose regimen of amoxycillin

B4B4- Two-visit of pulpectomy

Visit 2: Final root canal filling
7~10 days later
Rubber dam
Access root canals
Pulpectomy procedure

11

B4B4- Two-visit of pulpectomy

B5B5- Success rates

12