Pulpotomy treatment for primary teeth 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 Definition and rationale. Indications and contraindications. Materials and techniques. Pulpotomy technique (clinical procedures). Pulpotomy follow up. Summary and conclusions.

Maintain arch length, masticatory function and esthetics. Preservation of the primary teeth until their time of exfoliation is required to: Maintain arch length, masticatory function and esthetics.

Maintain arch length, masticatory function and esthetics. Preservation of the primary teeth until their time of exfoliation is required to: Maintain arch length, masticatory function and esthetics.

Maintain arch length, masticatory function and esthetics. Preservation of the primary teeth until their time of exfoliation is required to: Maintain arch length, masticatory function and esthetics. Eliminate pain, inflammation and infection.

Maintain arch length, masticatory function and esthetics. Preservation of the primary teeth until their time of exfoliation is required to: Maintain arch length, masticatory function and esthetics. Eliminate pain, inflammation and infection. 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 and rationale. Indications and contraindications. Materials and techniques. Pulpotomy technique (clinical procedures). Pulpotomy follow up. Summary and conclusions.

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.

Rationale of pulpotomy 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.

Rationale of pulpotomy After the pulpotomy is performed the remaining radicular pulp may be:

Rationale of pulpotomy After the pulpotomy is performed the remaining radicular pulp may be: Rendered inert by using formocresol that is bactericidal and “fixes” the pulp tissue.

Rationale of pulpotomy After the pulpotomy is performed the remaining radicular pulp may be: 2. Preserved trough minimal inflammatory insult by using an haemostatic agent / laser / elecrosurgery.

Rationale of pulpotomy After the pulpotomy is performed the remaining radicular pulp may be: 3. “Encouraged” to form a dentin bridge using calcium hydroxide or mineral trioxide aggregate (MTA).

Rationale of pulpotomy 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.

Rationale of pulpotomy 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 and contraindications. Materials and techniques. Pulpotomy technique (clinical procedures). Pulpotomy follow up. Summary and conclusions.

Indications for pulpotomy Pulp exposure caused by caries: “small” pulp exposure. Coronal pulp is still vital. 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.

Contraindications for pulpotomy Positive percussion test. The result of behavior problems and/or food impaction.

Contraindications for pulpotomy Tooth restorability.

Contraindications for pulpotomy Proximity of exfoliation, <2/3 of root length. (?)

Contraindications for pulpotomy Irreversible pulp damage.

Contraindications for pulpotomy Irreversible pulp damage.

Pulpotomy treatment for primary teeth Topics Definition and rationale. Indications and contraindications. Materials and techniques. Pulpotomy technique (clinical procedures). Pulpotomy follow up. Summary and conclusions.

Pulpotomy: materials / techniques What should be the characteristics of an ideal pulpotomy material/ technique?

Pulpotomy: materials / techniques 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.

Pulpotomy: materials / techniques 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.

Pulpotomy: materials / techniques Calcium hydroxide. Electrosurgery. Laser. Glutaraldehyde. Collagen. Mineral trioxide aggregate (MTA). Formocresol. Diluted formocresol. Ferric sulfate.

Pulpotomy: materials / techniques Calcium hydroxide. Electrosurgery. Laser. Glutaraldehyde. Collagen. Mineral trioxide aggregate (MTA). Formocresol. Diluted 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.

Pulpotomy: materials / techniques Calcium hydroxide. Electrosurgery. Laser. Glutaraldehyde. Collagen. Mineral trioxide aggregate (MTA). Formocresol. Diluted 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

Pulpotomy: electrosurgery 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

Pulpotomy: electrosurgery Requires the purchase of special equipment; an electrosurgery dental electrode. ±$ 1000.00

Pulpotomy: materials / techniques Calcium hydroxide. Electrosurgery. Laser. Glutaraldehyde. Collagen. Mineral trioxide aggregate (MTA). Formocresol. Diluted formocresol. Ferric sulfate.

Pulpotomy: laser Non-pharmaceutical technique. 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

Pulpotomy: materials / techniques Calcium hydroxide. Electrosurgery. Laser. Glutaraldehyde. Collagen. Mineral trioxide aggregate (MTA). Formocresol. Diluted 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.

Pulpotomy: glutaraldehyde 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.

Pulpotomy: glutaraldehyde 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.

Pulpotomy: glutaraldehyde 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).

Pulpotomy: materials / techniques Calcium hydroxide. Electrosurgery. Laser. Glutaraldehyde. Collagen. Mineral trioxide aggregate (MTA). Formocresol. Diluted 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 acid-soluble 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.

Pulpotomy: materials / techniques Calcium hydroxide. Electrosurgery. Laser. Glutaraldehyde. Collagen. Mineral trioxide aggregate (MTA). Formocresol. Diluted 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.

Pulpotomy: mineral trioxide aggregate Rationale Not been found to induce internal resorption, which has been observed in teeth treated with some other medicaments.

Pulpotomy: mineral trioxide aggregate 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.

Pulpotomy: mineral trioxide aggregate      Manf#: 1124-47      UPC#: 039645112441      Manf: QUIKRETE CO.      PORTLAND CEMENT 47LB     Retail Price: $10.55      Regular Price: $9.59      Checkout Price: $8.63

Pulpotomy: mineral trioxide aggregate 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.

Pulpotomy: materials / techniques Calcium hydroxide. Electrosurgery. Laser. Glutaraldehyde. Collagen. Mineral trioxide aggregate (MTA). Formocresol. Diluted 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. ?????????????????

Pulpotomy: materials / techniques Calcium hydroxide. Electrosurgery. Laser. Glutaraldehyde. Collagen. Mineral trioxide aggregate (MTA). Formocresol. Diluted 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.

Pulpotomy: ferric sulfate 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.

Pulpotomy: materials / techniques Comparisons

Pulpotomy: materials / techniques 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;32:404–407.

Pulpotomy: materials / techniques 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.

Pulpotomy: materials / techniques Comparisons MTA induces less undesirable responses and may be FC’s 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.

Pulpotomy: materials / techniques 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.

Pulpotomy: mineral trioxide aggregate      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.

Pulpotomy: materials / techniques Comparisons Success % Clinical Radiographic Electrosurgery 96% 84% Formocresol 100% 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

Pulpotomy: materials / techniques 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.

Pulpotomy: materials / techniques Comparisons Success % Clinical Radiographic Ferric sulfate 96.4% 92.0% Formocresol 97.5% 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 Definition and rationale. Indications and contraindications. Materials and techniques. Pulpotomy technique (clinical procedures). Pulpotomy follow up. Summary and conclusions.

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.

Technique: caries removal

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

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

Technique: caries removal If the pulp color is vivid red, the bleeding is moderate, proceed with the pulpotomy.

Technique: caries removal 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.

Technique: pulpotomy 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)

Technique: pulpotomy 1. After complete removal of the caries, open a wide access to the pulp chamber with high-sped.

Technique: pulpotomy 1. After complete removal of the caries, open a wide access to the pulp chamber with high-sped.

Technique: pulpotomy 1. After complete removal of the caries, open a wide access to the pulp chamber with high-sped.

Technique: pulpotomy 2. Judge the pulp condition based on the pulp tissue color, hemorrhage (none, moderate, profuse).

Technique: pulpotomy 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 Technique: pulpotomy Removing the coronal pulp

Technique: pulpotomy Removing the coronal pulp using a sharp excavator

Technique: pulpotomy Removing the coronal pulp Using slow speed large round bur

Removing the coronal pulp Technique: pulpotomy Removing the coronal pulp Using a 330 high speed bur

Place a cotton pellet to attain hemostasis Technique: pulpotomy Place a cotton pellet to attain hemostasis

Technique: pulpotomy Evaluate hemostasis “Unstoppable” bleeding No 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?

Technique: pulpotomy 6. Place the pulp dressing material of your choice and re-evaluate the pulp stumps.

Pulpotomy: materials / techniques Calcium hydroxide Formocresol. Diluted formocresol. Glutaraldehyde. Ferric sulfate. Mineral trioxide aggregate. Electrosurgery. Laser. Collagen.

Pulpotomy: materials / techniques Calcium hydroxide Formocresol. Diluted formocresol. Glutaraldehyde. Ferric sulfate. Mineral trioxide aggregate. Electrosurgery. Laser. Collagen.

Pulpotomy materials / formocresol Full strength or diluted Control hemorrhage with cotton pellets. Apply a cotton pellet moistoned with FC to the pulp stumps for 5 minutes. Evaluate the pulp stumps. Fill the pulp chamber with IRM.

Pulpotomy: materials / techniques Calcium hydroxide Formocresol. Diluted formocresol. Glutaraldehyde. Ferric sulfate. Mineral trioxide aggregate. Electrosurgery. Laser. Collagen.

Pulpotomy: ferric sulfate Control hemorrhage with cotton pellets. Apply (rub) FS to pulp stumps for 15 seconds. Rinse with water. Evaluate the pulp stumps.

Pulpotomy: ferric sulfate

Technique: pulpotomy Apply FS to pulp stumps for 15 seconds.

Pulpotomy: ferric sulfate 3. Rinse with water. 4. Evaluate the pulp stumps.

Technique: pulpotomy 7. Fill the pulp chamber with IRM.

Technique: pulpotomy 7. Fill the pulp chamber with IRM.

Technique: pulpotomy 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 Definition and rationale. Indications and contraindications. Materials and techniques. Pulpotomy technique (clinical procedures). Pulpotomy follow up. Summary and conclusions.

Clinical and radiographic. Pulpotomy / follow up Clinical and radiographic. Gingival and periodonatal health.

Clinical and radiographic. Pulpotomy / follow up Clinical and radiographic. Parulis / fistula.

Clinical and radiographic. Pulpotomy / follow up Clinical and radiographic. Obliteration.

Clinical and radiographic. Pulpotomy / follow up Clinical and radiographic. Interadicular radiolucencies.

Clinical and radiographic. Pulpotomy / follow up Clinical and radiographic. Periodontal health.

Clinical and radiographic. Pulpotomy / follow up Clinical and radiographic. 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?

Clinical and radiographic. Pulpotomy / follow up Clinical and radiographic. 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 Definition and rationale. Indications and contraindications. Materials and techniques. Pulpotomy technique (clinical procedures). Pulpotomy follow up. Summary and conclusions.

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.