PULPOTOMY

CONTENT
 Introduction
 Goal And Objective
 Definition
 Indication
 Contraindication
 Classification
 Devitalization
1. Single Sitting
2. Two Sitting
 Partial Pulpotomy
 Preservation
 Regeneration
 INTRODUCTION
• The main objective of pulp therapy is to
maintain the integrity and health of a tooth
affected by caries, traumatic injury, or other
causes.
• There are 2 methods of treating the involved
infected dental pulp for a primary tooth:
pulpotomy or pulpectomy.
 GOAL AND OBJECTIVE
• RADICULAR pulp should be remain asymptomatic
without adverse clinical signs or symptoms such
as sensitivity pain or swelling
• There should be no evidence of post –operative
external root resorption
• Internal root resorption should be self limiting
and stable
• There should be no harm to Succedaneous tooth
 AAPD Reference manual 2011/12
 definition-:

• PULPOTOMY CAN BE DEFINED AS THE COMPLETE

REMOVAL OF CORONAL PORTION OF THE DENTAL
PULP , FOLLOWED BY PLACEMENT OF SUITABLE
DRESSING OR MEDICAMENT THAT WILL PROMOTE
HEALING & PRESERVE VITALITY OF THE TOOTH
(Finn,1985 )
 INDICATION-:
 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
 CONTRAINDICATION :-

• History of unprovoked toothache

• Presence of sinus or swelling
• Evidence of necrotic/irreversibly damaged pulp
• Uncontrolled pulpal hemorrhage
• Periapical or bifurcation radiolucency
• Pathologic resorption of pulp
• Primary root length less than 2/3
CLASSIFICATION-:
• I. Vital Pulpotomy techniques
1. DEVITALIZATION: (mummification & cauterization)

 Single Sitting: 1. Formocresol

2. Electro surgery
3. Laser
5.sodium hypochlorite
6.other

 Two sitting: 1. Gysi triopaste

2. Easlick’s formaldehyde
3. Paraform devitalising paste
• 2.PRESERVATION: 1.Glutaraldehyde
2.Ferric sulphate

3.REGENERATION: (inductive & reparative)

1. Bone morphogenic protein
2. Hard setting calcium hydroxide
3. Freeze dried bone
4. Demineralized dentin
5. platelet rich protein
6. MTA

• II. Non-Vital pulpotomy techniques(mortal pulpotomy)

1.Beechwood cresol
2.formocresol
A. DEVITALIZATION (SINGLE SITTING)
• FORMOCRESOL PULPOTOMY TECHNIQUE

• First advocated by SWEET(1930)

• FORMOCRESOL SOLUTION:
*19% formaldehyde
*35% cresol
*15% glycerine (veichle)
Buckley’s solution: 1:5 conc. Of formocresol solution.
• To prepare a 1:5 conc. Of this formula-
• First thoroughly mix 3 part of glycerine with 1 part of distilled
water
• Then add 4 parts of this preparation to 1 part Buckley’s formocresol
& thoroughly mix again
Mechanism Of Action:

formocresol act through aldehyde group of

formaldehyde ,forming bond with side group of
amino acids of both bacteria and remaining pulp
tissue
Formocresol prevents tissue autolysis by
bonding to protein.
 Histolgic effect after application of
formocresol
• Massler and mansukhani 1959 have described the
following histological zones after application
formocresol-
1. Broad acidophilic zone of fixation
2. Pale-standing zone with diminished cellular activity
3. Zone of inflammatory cells
Technique for Pulpotomy
of the
Primary Teeth
1. Identification/Diagnosis of offending tooth based
upon diagnostic criteria (history, symptoms,
radiographic and clinical evaluation)

2. Informed Consent
– Explain to the parent/legal guardian the procedure.
Answer any questions to his/her satisfaction.
Document in the chart that you have been granted
verbal consent for the pulpotomy procedure.
3. Achieve adequate anesthesia
4. Place Rubber Dam -Rubber Dam Placement/Utilization is
a Necessity when performing pulp therapy!

5. With a slow speed

hand piece, remove
caries
6. With a high speed
hand piece and bur,
remove roof of pulp
chamber exposing all
canals
7. Remove all coronal
pulp with a slow speed
hand piece and a #4 or
#6 round bur. Remove
all vital tissue “ledges”
near canal orifices.
8. After all coronal pulp
tissue has been
removed, wet 2-3
cotton pellets with
formocresol and
squeeze between
2 x 2 gauze to remove
the excess. Place
cotton pellets in the
pulp chamber
(making sure that
they contact the pulp
tissue in the coronal
portion of the canals)
for 5 minutes.
9. If hemorrhage has ceased, place a thick mix of zinc oxide
and eugenol paste into the chamber (use an amalgam
carrier & a cotton pellet to ensure proper
condensation/placement).

10. Complete the planned restoration. (i.e. Stainless

Steel Crown) for long-term success.
.
.
• Formocresol Tissue Effects

– Highly toxic to cells

– Depresses fibroblastic activity and matrix
synthesis
– Blocks RNA and protein synthesis
– Chronic inflammatory response
– May be a systemic concern when doing multiple
treatments (i.e. OR case)
 DEVITALIZATION PULPOTOMY
(TWO STAGE)
• Two stage procedure involves use of paraformaldehyde
to fix the entire coronal & radicular pulp tissue.

• The medicaments used in this technique have a

devitalizing, mummifying and bactericidal action.

• Indications:
.Profuse bleeding
.Difficulty in controlling bleeding
.Spontaneous pain
.Slight purulence discharge
• Contraindication:
.Non restorable
.Necrotic
.Soon to be exfoliated
• Formula of each agent used are as follows:

– 1.GYSI TRIOPASTE FORMULA:

*tricresol 10 ml
*cresol 20 ml
*glyserine 4 ml
*paraformaldehyde 20 ml
*zinc oxide 60 gm
– 2.EASLICK’S PARAFORMALDEHYDE FORMULA:
*paraformaldehyde 1 gm
*procaine base 0.03 gm
*powdered asbestos 0.05 gm
*petroleum jelly 125 gm
*carimine to colour

– 3.PARAFORM DEVITALIZING PASTE:

*paraformaldehyde 1gm
*lignocaine 0.06 gm
*propylene glycol 0.05 ml
*carbowax 1.30 gm
*carmine to colour
 First appointment:

• Isolation of the affected teeth with rubber dam

– Preparation of the cavity , excavate the caries

• On excavation of deep caries pulp exposure is encountered , ensure that

the exposed site is free of debris
– Enlarge the cavity with round bur

– Cotton pellet with paraformaldehyde is placed in the

exposure site ,seal it for 1 to 2 weeks

• (formaldehyde gas liberated from the paraformaldehyde permeates

through the coronal & radicular pulp, fixing the pulp)
 Second appointment

– The roof of the pulp chamber is removed and

cleaned with saline and dried with cotton pellet

– The pulp chamber is then filled with antiseptic

paste and the tooth is restored.
 PARTIAL PULPOTOMY
used for traumatic exposures
procedure :
inflamed pulp tissue beneath an exposure is removed to
a depth of 1-3 mm to reach the deeper healthy tissue

– -Indicated for a vital , traumatically exposed, young

permanent tooth, especially one with an incompletely
formed apex.

– -Calcium hydroxide or MTA is used

Mechanism of action
• It is the ionic disassociation of calcium
hydroxide into calcium and hydroxyl ions and
their effect on bacteria and tissue which make
their use so successful.
• The mechanism of action of calcium hydroxide
is directly influenced by its high pH.
 USING MTA INSTEAD OF
FORMOCRESOL FOR PULPOTOMY
• In this new technique, the MTA paste is allowed to
cover the dry pulp stumps (instead of
formocresol).
• MTA is a powder composed of
-Tricalcium silicate,
-Bismuth oxide,
-Dicalcium silicate,
-Tricalciumaluminate,
-Tetracalciumaluminoferrite,
-Calcium sulfate dihydrate.
 PROPERTIES OF MTA (MINERAL
TRIOXIDE AGGREGATE)
• 93% clinical success rate

• Better biocompatibility

• Better sealing ability-prevents leakage in pulpal &

Periapical tissues

• Less time needed for procedure

• Promotes regeneration of original pulp tissue

• Dentinal bridge formation is seen

 ACTION

• Liquefaction necrosis of the superficial pulp

• •Neutralization of toxicity in deeper layers
• •Coagulative necrosis…Irritation of adjacent
pulp
• •Minor inflammation response… Hard tissue
barrier
 How does MTA work??

• Process of formation of hard tissue barrier is not yet

known
• Tri-calcium oxide + tissue fluids = calcium
hydroxide
.

Hard-tissue formation
• when MTA is placed in direct contact with human
tissues, material does the following:
• 1. Forms CH that releases calcium ions for cell
attachment and proliferation
• 2. Creates an antibacterial environment by its alkaline
pH
• 3. Modulates cytokine production
• 4. Encourages differentiation and migration of hard
tissue- producing cells
• 5. Forms Hydroxyapatite on the MTA surface and
provides a biologic seal
ELECTROSURGICAL PULPOTOMY

– > Mack & Dean,1993

– > Non-pharmacological technique

– > Non-chemical devitalisation ,electrocautery

carbonize & heat denatures, the pulp & bacterial
contamination
– > after completion ,the pulp chamber is filled with
ZnOE.
– The tooth is then restored with stainless steel crown

– > Disadvantage: contaminated pulp tissue does not

promote adequate current penetration .
– It cannot eliminate radicular pulp inflammation
 LASER PULPOTOMY:
•
> Non- pharmacologic haemostatic technique

• > Jeng-fen Liu et al in 1999- studied the effect of

Nd:YAG laser for pulpotomy in primary tooth-100%
success with no signs or symptoms
 PRESERVATION
• Chemicals which induce minimal insult to the tissue are used.

• They help to conserve vitality of the radicular pulp

• Chemicals used are glutaraldehyde (2-8%)and ferric sulphate
• Glutaraldehyde: (by Kopel,1979)
(1) superior fixation by cross-linkage
(2) diffusibility is limited
(3) excellent antimicrobial agent
(4) causes less necrosis of pulpal tissue

“IN HIGHER CONC. FOR LONGER EXPOSURE GLUTERALDEHYDE SHOWS

CYTOTOXIC & MUTAGENIC EFFECTS SAME AS FORMOCRESOL”
• Glutaraldehyde is available in 2%, 4%, 8% (2% is more
stable)
• In recent years, glutaraldehyde has been proposed as
an alternative to formocresol based on:
its superior fixative properties
self-limiting penetration,
low antigenticity
low toxicity
the elimination of cresol.
• Fuks et al. reported a success rate of 94·3% over 6
months that decreased to 82% after 25 months, which
is significantly lower than that reported for
formocresol.
 Histological effect glutaraldehyde
pulpotomy
• Inflammation is limited to area adjacent to medicament
placed
• Fixation is batter than
• It’s fixative and non biological properties do not promote
cell proliferation
• No dentinal bridge formation
• Because larger molecular size do not penetrate apex
(Pediatr Dent 16:403-9, 1994)

 Histological zones: Atkinson et al.

1. Zone of fixation
2. Zone of pro-inflammatory fibroblast
3. Vital pulp
 FERRIC SULPHATE- Fie et al 1991

1. It is a non aldehyde haemostatic compound

(1)astringent;
(2) less inflammation than formocresol
(3) 92.7% radiographic success rate.
(4)100% clinical success
(5)root resorption is not accelerated
(6) internal resorption similar to formocresol ,no systemic or
local side effects
• Ferric sulphate (15·5%)
• haemostatic agent in pulpotomy procedures. On contact
with blood, a ferric ion protein complex is formed, and the
membrane of this complex seals the cut vessels, producing
homeostasis.
• The agglutinated protein complex forms plugs which
occlude the capillary orifices, preventing blood clot
formation
• Fuks and her co-workers compared the pulpal responses of
ferric sulphate and formocresol in baboon teeth
• Outcomes for both medicaments were equal after 6
weeks, with 60% of teeth in each group presenting with
mild inflammation.
• Fei et al. reported
• for teeth treated with ferric sulphate and
formocresol. Although the overall success
rates were similar to those from Fuks and her
co-workers , the radiographic success rates for
ferric sulphate fell from 97·2% after 20
months to 92% after 48 months follow-up.
ZINC OXIDE EUGENOL: Magnusson 1971
• ZOE was the first agent to be used for preservation
(minimal devitalization, noninductive)" and is
currently used as a base material in pulpotomy.
• internal resorption is associated with eugenol
• When ZOE used as sub base ,eugenol directly
contacts with the vital tissue and causes moderate to
severe inflammatory response
 REINFORCED ZINC OXIDE-EUGENOL
PULPOTOMY: E.K. Hui-Derksen
• Reinforced ZOE contains
polymethyl methacrylate,
zinc oxide,
acetic acid, and
eugenol
• The radiographic, clinical, and overall success rates were
approximately 95%, 97%, and 94%, respectively

• The success rates indicate that the reinforced zinc oxide-eugenol

pulpotomy technique may be an acceptable treatment modality for
primary molars requiring vital pulp therapy
(Pediatr Dent 2013:35:43-6)
 NON-VITAL PULPOTOMY
•
Ideally, a non-vital tooth should be treated by
pulpectomy or root canal filling

• However, pulpectomy of a primary molar may

sometime be impracticable due to non-negotiable
root canals and also due to limited patient co-
operation.

• Hence, a two-stage pulpotomy technique is

advocated .
 SELECTION CRITERIA

• History of spontaneous pain

• Swelling ,redness or soreness of mucosa
• Tooth mobility
• Tenderness to percussion
• Radiographic evidence of root resorption
 TECHNIQUE
• 1st appointment
• Necrotic pulp is removed
• pulp chamber is irrigated with saline & dried with
cotton pellet
• Radicular pulp is treated with beachwood cersol
dipped cotton pellet
• Seal the cavity with temp. Cement for 1-2 weeks
• SECOND APPOINTMENT--

• Isolate the tooth

• Remove the temporary dressing & pellet containing
beechwood cresol
• if sign & symptoms persist then repeat the treatment
or extract the tooth
• If no symptoms pulp chamber is filled with antiseptic
paste
• Then it can be restored with stainless steel crown
 REGENERATION:
•
An ideal pulpotomy treatment should leave the radicular pulp
vital , healthy and completely enclosed within an odontoblast-
lined dentin chamber.

• Calcium hydroxide was the first agent used in pulpotomies

that demonstrated any capacity to induce regeneration of
dentin.
 Bone morphogenic protein
use of BMP(bone morphogenic protein) which contains a
factor(osteogenic proteins) capable of auto induction of reparative
dentin formation(stimulating induction & differentiation of
mesenchymal cells with varying degrees of dentinal bridge
formation)
• Bone morphogenic protein (BMP) is a generic term for a family of
proteins which have bone-inductive properties.
• Although these studies haves suggested that reparative dentine can
be induced on contact with BMP
• BMPs are classified as noncollagenous proteins.
• 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.
 BIODENTINE
• Biodentine is a new experimental tricalcium silicate
(Ca3SiO5) based inorganic non-metallic restorative cement
• commercialized and advertised as a “bioactive dentine
substitute”
• The material is claimed to possess
* faster setting time,
* increased compressive strength,
* increased density,
* decreased porosity
and early form of reparative dentine synthesis
• Biodentine and MTA are rich in calcium compounds, which
is converted to calcium hydroxide in aqueous solution.
• The dissociation of calcium and hydroxyl ions increases the
pH of the solution and promotes an unfavorable
environment for bacterial growth
composition Biodentine
calcium silicate,
calcium carbonate,
zirconium oxide

• The main component of the powder is tricalcium silicate,

with the addition of calcium carbonate (filler) and
zirconium oxide (radiopacifier).
• The liquid is a solution of calcium chloride with a water-
reducing agent.
• A recent study investigated Biodentine’s cytotoxicity and
Genotoxicity is equal to negative control group
 Technique
• The Biodentine Capsule is opened and tapped
gently on a hard surface to diffuse the powder.
• Five Drops of liquid from the single‐dose
dispenser will be poured into the capsule, after
which it is placed in a triturater for 30 seconds.
• The material is recovered with spatula and placed
inside the cavity with an amalgam carrier using a
cotton pellet material will be condensed without
excessive pressure on pulp stumps
 PLATELET RICH FIBRIN
• Platelet-Rich Fibrin (PRF) was first described by Choukroun
et al.

• obtained by removing the middle layer from a centrifuged

blood sample.
• PRF is a matrix of autologous fibrin, in which are embedded
a large quantity of platelet and leukocyte cytokines during
centrifugation
• a study conducted by Huang et al., who concluded that the
PRF causes proliferation of human Dental Pulp Cells and
increases the protein expression of Osteoprotegerin (OPG)
and Alkaline Phosphatase (ALP) activity.
Characteristics of blood samples after centrifugation. A
fibrin clot in the middle of the tube (PRF) between the
red blood corpuscles at the bottom and acellular
plasma at the top of the tube.
• PRF has a physiologic architecture that is favorable to
the healing, obtained due to the slow polymerization
process.
• PRF with immense regenerative potential will
definitely alter the surgical dentistry in the near
future
• Main disadvantage requiring blood sampling
• the field is still largely in its infancy.
• There are other material which are recently used in
pulpotomy of primary tooth
1. Enriched collagen
2. Hard setting calcium hydroxide
3. Freeze dried bone
4. Demineralized dentin
 Hard setting calcium hydoxide
• Pure calcium hydroxide are more caustic than
Hard-setting calcium hydroxide pastes (Dycal,
Life,…) but both have been shown to initiate
the same type of healing
 Conclusion
• Pulp therapy for primary dentition includes a variety
of treatment option depending on the vitality of
pulp. Conservative treatment is performed when
vital pulp remains because vitality is possible once
the irritation is removed.
 REFERENCES
• AAPD Reference manual 2011/12
• Peditr Dent,2008;30:237-246
• Peditr Dent,2008;30:211-9
• Massler &Mansukhani J Dent Child 1959;26:277
• Do we still need formocresol in Pediatr Dent :Michael
j.casas
• Vargas K, Packham B. Pediatr Dent 2006; 28: 511–517
• Sean F. Pediat Dent v33/no4,jul/aug
• Pediatr Dent 16:403-9, 1994
• Peditr Dent,1990;12:198
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