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Pediatric  Dental  Health

September 19, 2005
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Pulpotomy and Pulpectomy in Children

When the nerve or pulp tissue of a primary or permanent tooth is infected, it needs to be treated to prevent a dental abscess and loss of the tooth. The two methods of treating infected dental nerve tissue are the pulpotomy and pulpectomy. The ultimate objective of these procedures is to save the tooth, so that it will maintain the integrity and function of the dental arch.

This article will focus on the following topics in pediatric pulp treatment:
• Pulpotomy for Primary Teeth
• Alternatives to Formocresol in Primary Teeth
• Pulpotomy for Young Permanent Teeth
• Pulp Morphology
• Pulpectomy for Primary Teeth



Pulpotomy for Primary Teeth
• Definition: the surgical removal of the entire coronal pulp, leaving intact the vital radicular pulp within the canals.



Treatment Objectives for the Pulptomy
• (1) amputate the infected coronal pulp,
• (2) neutralize any residual infectious process,
• (2) preserve the vitality of the radicular pulp.




Indications for the Pulpotomy
• (1) cariously exposed primary teeth, when their retention is more advantageous than extraction.
• (2) when inflammation is confined to the coronal portion of the pulp.




Contraindications for the Pulpotomy
• (1) fistula or swelling,
• (2) the tooth crown is nonrestorable,
• (3) absent hemorrhage; profuse hemorrhage,
• (4) marked tenderness to percussion,
• (5) mobility,
• (6) radiolucency exists in the furcal or periradicular areas,
• (7) spontaneous pain, especially at night,
• (8) necrotic pulp,
• (9) dystrophic calcification (pulp stones).



Treatment Approaches for the Pulpotomy of Primary Teeth
• Devitalization: uses a 1:5 diluted formocresol (Buckley’s) technique, which results in partial devitalization with persistent chronic inflammation. Empirical success.
• Preservation: ferric sulfate maintains the vitality and normal histologic appearance of the entire radicular pulp.
• Regeneration: transforming growth factor (TGF) in the form of bone morphogenetic proteins, freeze-dried bone, and MTA.



Technique for Pulptomy of the Primary Teeth
• 1. Profound anesthesia for tooth and tissue.
• 2. Isolate the tooth to be treated with a rubber dam.
• 3. “Endo” access opening. Excavate all caries.
• 4. Remove the dentin roof of the pulp chamber.
• 5. Remove all coronal pulp tissue with a slow-speed No. 6 or 8 round bur or sharp spoon excavator.
• 6. Achieve hemostasis with dry cotton pellets under pressure.
• 7. Apply diluted formocresol (or 16% ferric sulfate solution) to pulp on cotton pellet for 3- 5 minutes. Pressure on pellet.
• 8. Prepare tooth for SSC.
• 9. Pulp stumps should appear dry.
• 10. Place a glass ionomer, ZOE, IRM, or MTA in contact with pulp stumps.
• 11. Place stainless steel crown (or bonded composite).



Alternatives to Using Formocresol in Primary Teeth
• Formocresol: (1) fixative; (2) chronic inflammation; (3) possibly mutagenic or carcinogenic; (4) 83.8% success rate.
• Glutaraldehyde: (1) superior fixation by cross-linkage; (2) diffusibility is limited; (3) excellent antimicrobial agent; (4) causes less necrosis of pulpal tissue; (5) causes less dystrophic calcification in pulp canals; (6) does not stimulate a significant immune response; (7) minimal systemic distribution.
• Ferric sulfate: (1) astringent; (2) forms a ferric ion-protein complex that mechanically occludes capillaries; (3) less inflammation than FC; (4) 92.7% success rate.
• Electrosurgery and laser: less successful than ferric sulfate or dilute formocresol.



Using MTA Instead of Formocresol for the 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, tricalcium aluminate, tetracalcium aluminoferrite, and calcium sulfate dihydrate.
• The cement’s setting time is 3 to 4 hours.
• MTA paste is obtained by mixing MTA powder with sterile saline at a 3:1 powder/saline ratio.
• IRM is place over the MTA.
• Promising.



Objectives for the CaOH Pulpotomy of Young Permanent Teeth (Apexogenesis)
• preserve radicular vitality,
• maximize the opportunity for apexogenesis (apical development and closure),
• enhance continual root dentin formation.




Clinical Technique for the CaOH Pulpotomy of Young Permanent Teeth
• 1. Anesthetize the tooth and isolate under a rubber dam.
• 2. Excavate all caries and establish a cavity outline.
• 3. Irrigate the cavity and lightly dry with cotton pellets.
• 4. Remove the roof of the pulp chamber.
• 5. Amputate the coronal pulp with a large low-speed round bur or a high-speed diamond stone with a light touch.CaOH Pulpotomy for Young Permanent Teeth - Technique.
• 6. Control hemorrhage with a cotton pellet applied with pressure or a damp pellet of hydrogen peroxide.
• 7. Place a calcium hydroxide mixture over the radicular pulp stumps at the canal orifices and dry with a cotton pellet.
• 8. Place quick-setting ZOE cement or resin-reinforced glass ionomer cement over the calcium hydroxide to seal and fill the chamber.



Definition and Treatment Objective for the Direct Pulp Cap
• Definition: the placement of a biocompatible agent (calcium hydroxide) on healthy pulp tissue that has been inadvertently exposed from caries excavation or traumatic injury.
• Treatment Objective: to seal the pulp against bacterial leakage, encourage the pulp to wall off the exposure site by initiating a dentin bridge, and maintain the vitality of the underlying pulp tissue regions.



Primary Tooth and Pulp Morphology
• An increased number of accessory canals, foramina - and porosity in pulpal floors of primary teeth.
• Primary root canals are more ribbon-like.
• Fine, filamentous pulp system.
• More difficult canal debridement.
• Complete extirpation of pulp remnants almost impossible. Increased potential of root perforation.
• Root canal opening is several mm coronal to the radiographic apex.



Definition of Pulpectomy for Primary Teeth
• A nonvital technique.
• The removal of necrotic pulp tissue followed by filling the root canals with resorbable cement.



Treatment Objectives for Primary Tooth Pulpectomy
• (1) Maintain the tooth free of infection,
• (2) Biomechanically cleanse and obturate the root canals,
• (3) Promote physiologic root resorption, and
• (4) Hold the space for the erupting permanent tooth.



Indications for Pulpectomy of Primary Teeth
• (1) Cooperative patient,
• (2) Teeth with poor chance of vital pulp treatment,
• (3) Strategic importance for space maintenance,
• (4) Absence of severe root resorption,
• (5) Absence of surrounding bone loss from infection,
• (6) Expectation of restorability,
• (7) Pulpless primary teeth with sinus tracts,
• (8) Pulpless primary teeth in hemophiliacs,
• (9) Pulpless primary teeth next to the line of a palatal cleft,
• (10) Pulpless primary teeth when space maintainers or continued supervision are not feasible (handicapped or isolated children.



Contraindications for Primary Tooth Pulpectomy
• 1. Teeth with nonrestorable crowns,
• 2. Periradicular involvement extending to the permanent tooth bud,
• 3. Pathologic resorption of at least one-third of the root with a fistulous sinus tract,
• 4. Excessive internal resorption,
• 5. Extensive pulp floor opening into the bifurcation,
• 6. Systemic illness such: as congenital or rheumatic heart disease, hepatitis, leukemia, and children on long-term corticosteroid therapy, or those who are immunocompromised,
• 7. Primary teeth with underlying dentigerous or follicular cysts.




Clinical Technique for Primary Tooth Pulpectomy
• 1. First, penicillin should be immediately prescribed for a period of 4 to 7 days in case of a nondraining alveolar abscess.
• 2. Enter pulp chamber. Extirpate the pulp with broaches. Irrigate.
• 3. File short of radiograpahic apex. Instrument only to point of resistance. Size 35 = largest file size for primary molars.
• 4. Remove organic debris: irrigate periodically with dilute sodium hypochlorite or saline.
• 5. Dry the canals with paper points.
• 6. Obturate with ZOE or resorbable Kri paste.
• 7. Mix ZOE as a slurry and carry into the canals using either paper points, a syringe, or a lentulo spiral root canal filler.
• 8. Then, pack the orfice area with a stiffer mix of ZOE.
• 9. Fill the remainder of pulp chamber with a reinforced ZOE or a glass ionomer.
• 10. Place stainless steel crown.



Using Iodoform Paste for Pulpectomy of Primary Teeth
• Kri paste: highly resorbable, bacteriocidal, healthy tissue ingrowth at apex.
• An iodoform 80% compound which also contains parachlorophenol 2%, camphor 5%, and menthol 1%.
• Success rates of 84% with the Kri paste group versus 65% with the ZOE group.
• Overfills more successful (Kri paste 79% vs. ZOE 41%).



EXTERNAL LINK:
An article in Critical Reviews in Oral Biology and Medicine discusses unresolved issues in endodontics. The article deals with disagreements regarding the clinical management of pulpal exposures by caries in the adult dentition, definitions of success and failure of endodontic therapy, and causes of and measures to control infections of the root canal system.

Bergenholtz G, Spεngberg, L: Controversies in endodontics. Crit Rev Oral Biol Med 15(2):99-114 (2004)


Copyright ©2005 Daniel Ravel DDS, FAAPD

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