Chapter 11: Vital Pulp therapy, Pulpotomy and Apexification

Q: Indirect pulp capping

 Objective:
The outer layers of carious dentin (infected dentin) are removed

Thus, most of the bacteria are eliminated from the lesion.

When the lesion is sealed - the substrate on which the bacteria act to produce acid is also removed.

With the arrest of the carious process - the reparative mechanism is able to lay down additional
dentin and avoiding pulp exposure.

 Rationale:
 Disinfection of the residual affected dentin is more readily accomplished.
 It eliminates the need for more difficult pulp therapy by arresting the carious process and
allowing the pulp reparative process to occur.
 Patient comfort is immediate.
 Rampant dental decay is halted when all carious teeth are treated.

 Diagnostic data:
 History – tolerable, dull pain with mild discomfort associated with eating
 Clinical examination – large carious lesion without frank pulp exposure, positive response
to EPT, thermal stimulation, test cavity and percussion
 Radiographic examination - large carious lesion with a possible pulp exposure, extent of
caries penetration depth is up to 3/4th of the entire thickness of dentin or more

 Procedure
 Stepwise excavation - caries is removed in increments in two or more appointments over a
period of few months; indicated for deep carious lesions with no symptoms of irreversible
pulpitis. Objectives of this technique are:
 Arrest caries lesion progression and allow formation of reparative dentin
 Pulpal exposure is less likely in vital teeth with deep carious lesions
 Two-step stepwise excavation - recommended for the following reasons:
 Avoids unintentional pulpal exposure which may deteriorate the pulpal prognosis.
 The dentist gets a chance to assess the reaction of the tooth as well as gain
information of the changes in caries activity.
 Gives an opportunity to remove the slowly progressing lesion in slightly infected,
discolored, demineralized dentin before the placement of the final restoration
Q: Pulp capping
 Definition: Direct pulp capping is defined as a procedure in which the exposed vital pulp is covered
with a protective dressing or base placed directly over the site of exposure in an attempt to
preserve pulpal vitality.

 Indications:
1. Asymptomatic (no spontaneous pain, normal response to thermal testing, and pulp is vital
before procedure)
2. Small exposure - less than 0.5 mm in diameter
3. Hemorrhage from the exposure site is easily controlled (within 10 minutes)
4. The exposure occurred is clean and uncontaminated (rubber dam isolation)
5. Atraumatic exposure and little desiccation of the tooth with no evidence of aspiration of
blood into the dentin (dentin blushing)

 Technique
Q: Pulpotomy
 Definition: It is defined as a procedure in which a portion of the exposed coronal vital pulp is
surgically removed as a means of preserving the vitality and function of the remaining radicular
portion.
 Objectives:
 Preservation of vitality of the radicular pulp
 Relief of pain in patients with acute pulpalgia and inflammatory changes in the tissue
 Ensuring the continuation of normal apexogenesis in immature permanent teeth by
retaining the vitality of the radicular pulp
 Rationale:
The inflamed coronal portion of the pulp is removed and a dressing is placed over the pulp stump
to protect it and to promote healing - Ca(OH)2 or MTA.

Severe inflammation produces limited reparative dentin devoid of dentinal tubules.

Mild inflammation produces reparative dentin with varying numbers of dentinal tubules.

Although the term “bridge” implies a solid barrier and a seal between the surface of the new
reparative dentin and the pulp, communications exist in the form of openings.

Therefore, in the presence of severe inflammation of the pulp, pulpotomy procedures to preserve
pulp vitality are contraindicated.

Indications Contraindications
 Mechanical/carious exposure in permanent  Patients with irreversible pulpitis
teeth with incomplete root formation.  Abnormal sensitivity to heat and cold
 Traumatic exposures of longer duration  Chronic pulpalgia
where coronal pulp is likely to be inflamed  Tenderness to percussion or palpation
in young permanent teeth. Ex: child’s because of pulpal disease
permanent anterior tooth with a wide-open  Periradicular radiographic changes resulting
apex fractured during sports or in an from extension of pulpal disease into the
automobile accident. periradicular tissues
 In pulpally involved permanent teeth of  Marked constriction of the pulp chamber or
children in which the root apex is not root canals (calcification)
completely formed
 pulp extirpation and obturation are
contraindicated because of
immature root and wide-open
foramen
 extraction is not justified because of
effect on eruption of adjacent teeth
and the development of the dental
arches.
 The open foramen contraindicates
root canal therapy
Pulpotomy permits the completion of
apexogenesis - the physiological maturation of
the root
  Classification
 The pulpotomy procedure can be classified on the basis of the following:
 Amount of pulpal tissue removed
o Partial pulpotomy (Cvek’s pulpotomy)
o Complete pulpotomy (cervical pulpotomy)
 Type of medicament employed
o Calcium hydroxide pulpotomy
o MTA pulpotomy
o Formocresol pulpotomy
 There are two types of pulpotomy based on the amount of pulpal tissue removed:
 Partial pulpotomy (Cvek’s pulpotomy): only a portion of the coronal pulp is removed/
removal of tissues until normal tissue that is free of inflammation is reached before
placing a medicament.
 Complete pulpotomy (Cervical pulpotomy): complete removal of the coronal portion
of the dental pulp, followed by placement of a suitable dressing or medicament
promoting healing and preserve the vitality

Q: Cvek’s Pulpotomy
 Also known as partial pulpotomy
 Uninfected vital pulp tissue can be preserved in root canal – by surgical excision of the inflamed
coronal pulp
 Removal of infected portion of pulp:
 rapid relief of pulpalgia
 and further remaining tissue undergoes repair, while completing apexogenesis
 Recommended for:
 Crown fractured teeth having pinpoint exposure – that can be treated within 15-18 hrs of
accident
 Carious exposure of an asymptomatic permanent tooth with open apex
Q: Apexification
 Definition: Apexification is defined as a method to induce a calcific barrier across an open apex of
an immature, pulpless tooth.
 Objective: to induce either closure of the open apical third of the root canal or the formation of an
apical “calcific barrier” against which obturation can be achieved.
 There are 2 techniques in which apexification can be done:
1. Multiple step apexification with calcium hydroxide
2. Single step apexification with MTA/CSC cements
Q: Pulp capping agents

Q: Apexogenesis
 Definition: it is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit
continued growth of the root and closure of the open apex
 It is physiological process – induces normal root development in an inflamed/infected VITAL tooth